Provider Demographics
NPI:1467770644
Name:KERNERSVILLE PHARMACY LLC
Entity Type:Organization
Organization Name:KERNERSVILLE PHARMACY LLC
Other - Org Name:KERNERSVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:336-497-4511
Mailing Address - Street 1:841 OLD WINSTON RD STE 90
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-7145
Mailing Address - Country:US
Mailing Address - Phone:336-497-4511
Mailing Address - Fax:336-497-4511
Practice Address - Street 1:841 OLD WINSTON RD STE 90
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-7145
Practice Address - Country:US
Practice Address - Phone:336-497-4511
Practice Address - Fax:336-497-4511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC105213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2124794OtherPK
NC0347780Medicaid
2124794OtherPK