Provider Demographics
NPI:1548378300
Name:A&B WYATT ENTERPRISES, INC.
Entity Type:Organization
Organization Name:A&B WYATT ENTERPRISES, INC.
Other - Org Name:THE DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-573-2200
Mailing Address - Street 1:PO BOX 258
Mailing Address - Street 2:
Mailing Address - City:STONEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27048-0258
Mailing Address - Country:US
Mailing Address - Phone:336-573-2200
Mailing Address - Fax:336-573-2201
Practice Address - Street 1:104 N HENRY ST
Practice Address - Street 2:
Practice Address - City:STONEVILLE
Practice Address - State:NC
Practice Address - Zip Code:27048
Practice Address - Country:US
Practice Address - Phone:336-573-2200
Practice Address - Fax:336-573-2201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC081493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0795775Medicaid
NC7704002OtherMEDICAID DME SUPPLIER NUM
NC3440601OtherNCPDP NUMBER
NC0795775Medicaid