Provider Demographics
NPI:1225143266
Name:ISLAND PHARMACY INC
Entity Type:Organization
Organization Name:ISLAND PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:252-473-5801
Mailing Address - Street 1:PO BOX 2027
Mailing Address - Street 2:
Mailing Address - City:MANTEO
Mailing Address - State:NC
Mailing Address - Zip Code:27954-2027
Mailing Address - Country:US
Mailing Address - Phone:252-473-5801
Mailing Address - Fax:252-473-2130
Practice Address - Street 1:210 S HWY 64
Practice Address - Street 2:
Practice Address - City:MANTEO
Practice Address - State:NC
Practice Address - Zip Code:27954
Practice Address - Country:US
Practice Address - Phone:252-473-5801
Practice Address - Fax:252-473-2130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC094353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0285163Medicaid
NC0285294Medicaid
2068569OtherPK
NC0285163Medicaid