Provider Demographics
NPI:1235237108
Name:CREEDMOOR DRUG COMPANY
Entity Type:Organization
Organization Name:CREEDMOOR DRUG COMPANY
Other - Org Name:CREEDMOOR DRUG COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:919-528-0041
Mailing Address - Street 1:PO BOX 523
Mailing Address - Street 2:
Mailing Address - City:CREEDMOOR
Mailing Address - State:NC
Mailing Address - Zip Code:27522-0523
Mailing Address - Country:US
Mailing Address - Phone:919-528-0041
Mailing Address - Fax:
Practice Address - Street 1:108 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CREEDMOOR
Practice Address - State:NC
Practice Address - Zip Code:27522
Practice Address - Country:US
Practice Address - Phone:919-528-0041
Practice Address - Fax:919-528-3185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC043373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2065737OtherPK
NC0395186Medicaid
NC1232740001Medicaid