Provider Demographics
NPI:1578791596
Name:MEBANE DRUG STORE INC
Entity Type:Organization
Organization Name:MEBANE DRUG STORE INC
Other - Org Name:MEBANE DRUG STORE, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ISAAC
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-392-5857
Mailing Address - Street 1:4918 WARFIELD DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-9350
Mailing Address - Country:US
Mailing Address - Phone:336-392-5857
Mailing Address - Fax:
Practice Address - Street 1:101 E CLAY ST
Practice Address - Street 2:
Practice Address - City:MEBANE
Practice Address - State:NC
Practice Address - Zip Code:27302-2434
Practice Address - Country:US
Practice Address - Phone:919-304-3784
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-29
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3415785OtherNCPDP PROVIDER IDENTIFICATION NUMBER