Provider Demographics
NPI:1548229933
Name:MEDI-K INC
Entity Type:Organization
Organization Name:MEDI-K INC
Other - Org Name:MEDSOURCE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:DALTON
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:252-522-0353
Mailing Address - Street 1:505 W VERNON AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-3700
Mailing Address - Country:US
Mailing Address - Phone:252-522-0353
Mailing Address - Fax:252-523-0058
Practice Address - Street 1:505 W VERNON AVE
Practice Address - Street 2:STE 100
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-3700
Practice Address - Country:US
Practice Address - Phone:252-522-0353
Practice Address - Fax:252-523-0058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC042333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2068888OtherPK
NC0545335Medicaid
NC7701289Medicaid
NC0545335Medicaid