Provider Demographics
NPI:1619151404
Name:FISHER RX DIRECT LLC
Entity Type:Organization
Organization Name:FISHER RX DIRECT LLC
Other - Org Name:FISHER RX DIRECT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-482-7963
Mailing Address - Street 1:1157 E MARION ST STE 1
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-4890
Mailing Address - Country:US
Mailing Address - Phone:704-482-7963
Mailing Address - Fax:704-482-7967
Practice Address - Street 1:1157 E MARION ST STE 1
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-4890
Practice Address - Country:US
Practice Address - Phone:704-482-7963
Practice Address - Fax:704-482-7967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NC099703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0235924Medicaid
3409958OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NC7704811Medicaid
NC0235924Medicaid