Provider Demographics
NPI:1326146135
Name:GLEN RAVEN PHARMACY, INC
Entity Type:Organization
Organization Name:GLEN RAVEN PHARMACY, INC
Other - Org Name:GLEN RAVEN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:AUGUST
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:IV
Authorized Official - Credentials:RPH
Authorized Official - Phone:336-584-3736
Mailing Address - Street 1:1902 W WEBB AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27217-1062
Mailing Address - Country:US
Mailing Address - Phone:336-584-3736
Mailing Address - Fax:336-584-3735
Practice Address - Street 1:1902 W WEBB AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217-1062
Practice Address - Country:US
Practice Address - Phone:336-584-3736
Practice Address - Fax:336-584-3735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC074683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3437250OtherNCPDP
NC7703170Medicaid
NC0015884Medicaid
NC1309120001Medicare NSC