Provider Demographics
NPI:1235158213
Name:REALO DISCOUNT DRUG STORES INC
Entity Type:Organization
Organization Name:REALO DISCOUNT DRUG STORES INC
Other - Org Name:REALO DISCOUNT DRUGS OF TRENTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAIGE
Authorized Official - Middle Name:H
Authorized Official - Last Name:KILLINGSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, RPH
Authorized Official - Phone:252-448-2901
Mailing Address - Street 1:125 W JONES ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NC
Mailing Address - Zip Code:28585-7599
Mailing Address - Country:US
Mailing Address - Phone:252-448-2901
Mailing Address - Fax:252-448-1100
Practice Address - Street 1:125 W JONES ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NC
Practice Address - Zip Code:28585-7599
Practice Address - Country:US
Practice Address - Phone:252-448-2901
Practice Address - Fax:252-448-1100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC59523336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7701571Medicaid
NC0255596Medicaid
NC0271060002Medicare NSC
NC0255596Medicaid