Provider Demographics
NPI:1417205410
Name:OLD MAIN PHARMACY INC
Entity Type:Organization
Organization Name:OLD MAIN PHARMACY INC
Other - Org Name:ROWLAND'S OLD MAIN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:910-422-3774
Mailing Address - Street 1:PO BOX 2816
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-2816
Mailing Address - Country:US
Mailing Address - Phone:910-422-3774
Mailing Address - Fax:910-422-3752
Practice Address - Street 1:101 S BOND ST
Practice Address - Street 2:
Practice Address - City:ROWLAND
Practice Address - State:NC
Practice Address - Zip Code:28383-9639
Practice Address - Country:US
Practice Address - Phone:910-422-3774
Practice Address - Fax:910-422-3752
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OLD MAIN PHARMACY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-22
Last Update Date:2012-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11324333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy