Provider Demographics
NPI:1215042536
Name:EBP LLC
Entity Type:Organization
Organization Name:EBP LLC
Other - Org Name:EAST BURKE PHARMACY, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SUDDERTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-355-3365
Mailing Address - Street 1:345 DEERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5009
Mailing Address - Country:US
Mailing Address - Phone:828-355-3365
Mailing Address - Fax:828-264-0543
Practice Address - Street 1:300 MAIN AVE W
Practice Address - Street 2:
Practice Address - City:HILDEBRAN
Practice Address - State:NC
Practice Address - Zip Code:28637-8315
Practice Address - Country:US
Practice Address - Phone:828-397-3420
Practice Address - Fax:828-397-3477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC125343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2150943OtherPK
NC0125542Medicaid
3438618OtherNCPDP PROVIDER IDENTIFICATION NUMBER