Provider Demographics
NPI:1568827020
Name:COUNTRY PHARMACY INC
Entity Type:Organization
Organization Name:COUNTRY PHARMACY INC
Other - Org Name:COUNTRY PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUERKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:980-322-5762
Mailing Address - Street 1:8914 MAGNOLIA ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-7848
Mailing Address - Country:US
Mailing Address - Phone:980-322-5762
Mailing Address - Fax:704-209-3316
Practice Address - Street 1:610 W MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:ROCKWELL
Practice Address - State:NC
Practice Address - Zip Code:28138-9415
Practice Address - Country:US
Practice Address - Phone:704-209-3313
Practice Address - Fax:704-209-3316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-28
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC127563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159364OtherPK
NC1568827020Medicaid
1568827020Medicare NSC