Provider Demographics
NPI:1609903301
Name:BAKERSVILLE PHARMACY INC
Entity Type:Organization
Organization Name:BAKERSVILLE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:SIDES
Authorized Official - Suffix:III
Authorized Official - Credentials:RPH
Authorized Official - Phone:828-688-3241
Mailing Address - Street 1:PO BOX 920
Mailing Address - Street 2:580 SOUTH HWY 226
Mailing Address - City:BAKERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28705
Mailing Address - Country:US
Mailing Address - Phone:828-688-3241
Mailing Address - Fax:828-688-9463
Practice Address - Street 1:580 SOUTH HWY 226
Practice Address - Street 2:
Practice Address - City:BAKERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28705
Practice Address - Country:US
Practice Address - Phone:828-688-3241
Practice Address - Fax:828-688-9463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3867332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7702249Medicaid
NC0788110001Medicare ID - Type Unspecified