Provider Demographics
NPI:1285670174
Name:THE DRUG STORE INC
Entity Type:Organization
Organization Name:THE DRUG STORE INC
Other - Org Name:LEGACY CONSULTANT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-729-0729
Mailing Address - Street 1:3064 SALEM INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-8854
Mailing Address - Country:US
Mailing Address - Phone:336-831-0500
Mailing Address - Fax:855-760-7126
Practice Address - Street 1:3064 SALEM INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-8854
Practice Address - Country:US
Practice Address - Phone:336-831-0500
Practice Address - Fax:855-760-7126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC129133336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0347064Medicaid
2069115OtherPK
VA8519412Medicaid
5532560001Medicare UPIN
U5DOJOtherDRUG ENFORCEMENT ADMIN.