Provider Demographics
NPI:1225138118
Name:MT AIRY DRUG INC
Entity Type:Organization
Organization Name:MT AIRY DRUG INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:336-786-5506
Mailing Address - Street 1:701 WEST PINE ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:MT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030
Mailing Address - Country:US
Mailing Address - Phone:336-786-5506
Mailing Address - Fax:336-786-6867
Practice Address - Street 1:701 WEST PINE ST
Practice Address - Street 2:SUITE 500
Practice Address - City:MT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030
Practice Address - Country:US
Practice Address - Phone:336-786-5506
Practice Address - Fax:336-786-6867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC08106333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0865627Medicaid
4571250001Medicare ID - Type Unspecified