Provider Demographics
NPI:1265459614
Name:MEDIPACK PHARMACY LLC
Entity Type:Organization
Organization Name:MEDIPACK PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:JONES
Authorized Official - Last Name:WHITSELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, MBA
Authorized Official - Phone:336-773-1013
Mailing Address - Street 1:3917 WESTPOINT BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6723
Mailing Address - Country:US
Mailing Address - Phone:336-773-1013
Mailing Address - Fax:
Practice Address - Street 1:3917 WESTPOINT BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6723
Practice Address - Country:US
Practice Address - Phone:336-773-1013
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336I0012X
NC084323336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3435319OtherNABP IDENTIFICATION
NC0347172Medicaid
NC3435319OtherNABP IDENTIFICATION