Provider Demographics
NPI:1417292244
Name:INDIAN TRAIL PHARMACY, INC.
Entity Type:Organization
Organization Name:INDIAN TRAIL PHARMACY, INC.
Other - Org Name:INDIAN TRAIL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER/TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:M
Authorized Official - Last Name:STINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-821-7617
Mailing Address - Street 1:106 INDIAN TRAIL RD S
Mailing Address - Street 2:PO BOX 86
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-9669
Mailing Address - Country:US
Mailing Address - Phone:704-821-7617
Mailing Address - Fax:704-821-0177
Practice Address - Street 1:106 INDIAN TRAIL RD S
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-9669
Practice Address - Country:US
Practice Address - Phone:704-821-7617
Practice Address - Fax:704-821-0177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC026703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0905117Medicaid
3401128OtherNABP
NC0651400001Medicare NSC