Provider Demographics
NPI:1366468225
Name:TALL OAKS PHARMACY
Entity Type:Organization
Organization Name:TALL OAKS PHARMACY
Other - Org Name:TALL OAKS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRUTH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:704-658-9814
Mailing Address - Street 1:8703 STUDLEY RD STE B
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-2016
Mailing Address - Country:US
Mailing Address - Phone:704-658-9814
Mailing Address - Fax:704-658-0721
Practice Address - Street 1:798 OAK RIDGE FARM HWY
Practice Address - Street 2:STE C
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-7923
Practice Address - Country:US
Practice Address - Phone:704-658-9814
Practice Address - Fax:704-658-0721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC092733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0497529Medicaid
3405520OtherNCPDP PROVIDER IDENTIFICATION NUMBER
3405520OtherNCPDP PROVIDER IDENTIFICATION NUMBER