Provider Demographics
NPI:1578826327
Name:MEDI-K INC
Entity Type:Organization
Organization Name:MEDI-K INC
Other - Org Name:MEDSOURCE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DALTON
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-522-0353
Mailing Address - Street 1:2202 HWY 250 N
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28504
Mailing Address - Country:US
Mailing Address - Phone:252-522-2200
Mailing Address - Fax:252-522-2202
Practice Address - Street 1:2202 US HIGHWAY 258N
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28504-7223
Practice Address - Country:US
Practice Address - Phone:252-522-2200
Practice Address - Fax:252-522-2202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-18
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC112933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2135610OtherPK
NC0545706Medicaid