Provider Demographics
NPI:1215024419
Name:ARCHDALE DRUG CO INC
Entity Type:Organization
Organization Name:ARCHDALE DRUG CO INC
Other - Org Name:DEEP RIVER DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOSKINS
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:336-434-2776
Mailing Address - Street 1:2401 HICKSWOOD RD STE B
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265-1538
Mailing Address - Country:US
Mailing Address - Phone:336-454-3784
Mailing Address - Fax:336-454-3830
Practice Address - Street 1:2401 HICKSWOOD RD STE B
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-1538
Practice Address - Country:US
Practice Address - Phone:336-454-3784
Practice Address - Fax:336-454-3830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
NC089443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7704414Medicaid
2067702OtherPK
NC0418165Medicaid
2067702OtherPK