Provider Demographics
NPI:1518014679
Name:DOROTHEA DIX HOSPITAL PHARMACY
Entity Type:Organization
Organization Name:DOROTHEA DIX HOSPITAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:
Authorized Official - Last Name:UPDEGRAVE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:919-733-5266
Mailing Address - Street 1:CENTRAL BILLING OFFICE DHHS CONTROLLERS OFFICE
Mailing Address - Street 2:2021 MAIL SERVICE CENTER
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27699-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:820 S BOYLAN AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603-2246
Practice Address - Country:US
Practice Address - Phone:919-733-5266
Practice Address - Fax:919-733-1544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC026003336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3409922OtherOTHER ID NUMBER
3409922OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NC344001Medicaid