Provider Demographics
NPI:1568731594
Name:INNES STREET DRUG CO. INC. #3
Entity Type:Organization
Organization Name:INNES STREET DRUG CO. INC. #3
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT/ PHARMACIST-MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:WELDON
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-636-1712
Mailing Address - Street 1:1706 W INNES ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-2552
Mailing Address - Country:US
Mailing Address - Phone:704-636-1712
Mailing Address - Fax:704-637-0324
Practice Address - Street 1:1706 W INNES ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2552
Practice Address - Country:US
Practice Address - Phone:704-636-1712
Practice Address - Fax:704-637-0324
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INNES STREET DRUG CO.,INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC056093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0805473Medicaid
NCQ371140001OtherMEDICARE PTAN