Provider Demographics
NPI:1568754844
Name:EASTOVER DRUG, LLC
Entity Type:Organization
Organization Name:EASTOVER DRUG, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:BRISSON
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:910-483-4555
Mailing Address - Street 1:3591 DUNN RD
Mailing Address - Street 2:
Mailing Address - City:EASTOVER
Mailing Address - State:NC
Mailing Address - Zip Code:28312-8794
Mailing Address - Country:US
Mailing Address - Phone:910-483-4555
Mailing Address - Fax:910-483-0996
Practice Address - Street 1:3591 DUNN RD
Practice Address - Street 2:
Practice Address - City:EASTOVER
Practice Address - State:NC
Practice Address - Zip Code:28312-8794
Practice Address - Country:US
Practice Address - Phone:910-483-4555
Practice Address - Fax:910-483-0996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-05
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10486332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0266477Medicaid
NC0266477Medicaid