Provider Demographics
NPI:1326613894
Name:YE OLDE SHOPPE LLC
Entity Type:Organization
Organization Name:YE OLDE SHOPPE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:RAGLAND
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:IV
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:910-620-2317
Mailing Address - Street 1:2571 SAINT JAMES DR
Mailing Address - Street 2:UNIT 102-C
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-8201
Mailing Address - Country:US
Mailing Address - Phone:910-946-7999
Mailing Address - Fax:
Practice Address - Street 1:2571 SAINT JAMES DR
Practice Address - Street 2:UNIT 102-C
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-8201
Practice Address - Country:US
Practice Address - Phone:910-946-7999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy