Provider Demographics
NPI:1588827372
Name:GO PHARMACY INC
Entity Type:Organization
Organization Name:GO PHARMACY INC
Other - Org Name:GO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRENTON
Authorized Official - Middle Name:
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-398-5467
Mailing Address - Street 1:PO BOX 479
Mailing Address - Street 2:
Mailing Address - City:LAKE WACCAMAW
Mailing Address - State:NC
Mailing Address - Zip Code:28450-0479
Mailing Address - Country:US
Mailing Address - Phone:910-646-6614
Mailing Address - Fax:910-646-6615
Practice Address - Street 1:203 CHAUNCEY TOWN RD STE B
Practice Address - Street 2:
Practice Address - City:LAKE WACCAMAW
Practice Address - State:NC
Practice Address - Zip Code:28450-2003
Practice Address - Country:US
Practice Address - Phone:910-646-6614
Practice Address - Fax:910-646-6615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336I0012X
NC111913336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7705424Medicaid
2117971OtherPK
NC0245886Medicaid
NC7705424Medicaid