Provider Demographics
NPI:1578830105
Name:ROCKY MOUNT MEDICAL PARK PHARMACY, INC
Entity Type:Organization
Organization Name:ROCKY MOUNT MEDICAL PARK PHARMACY, INC
Other - Org Name:ROCKY MOUNT MEDICAL PARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:252-443-7979
Mailing Address - Street 1:901 N WINSTEAD AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-8467
Mailing Address - Country:US
Mailing Address - Phone:252-443-7979
Mailing Address - Fax:252-443-7419
Practice Address - Street 1:901 N WINSTEAD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-8467
Practice Address - Country:US
Practice Address - Phone:252-443-7979
Practice Address - Fax:252-443-7419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC53393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC00335398Medicaid
NC3428035OtherNCPDP
NC00335398Medicaid