Provider Demographics
NPI:1235483785
Name:TRIAD ADULT AND PEDIATRIC MEDICINE INC
Entity Type:Organization
Organization Name:TRIAD ADULT AND PEDIATRIC MEDICINE INC
Other - Org Name:TRIAD ADULT AND PEDIATRIC MED - GCH WENDOVER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:HALLISEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-355-9908
Mailing Address - Street 1:1046 E WENDOVER AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-6712
Mailing Address - Country:US
Mailing Address - Phone:336-355-9908
Mailing Address - Fax:336-275-1033
Practice Address - Street 1:1046 E WENDOVER AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6712
Practice Address - Country:US
Practice Address - Phone:336-355-9908
Practice Address - Fax:336-275-1033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-06
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X
NC113853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC344047BMedicaid
2137806OtherPK