Provider Demographics
NPI:1619543121
Name:UPTOWN PHARMACY LLC
Entity Type:Organization
Organization Name:UPTOWN PHARMACY LLC
Other - Org Name:UPTOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:CORINNE
Authorized Official - Middle Name:EDWARDS
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:336-612-3434
Mailing Address - Street 1:901 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-6012
Mailing Address - Country:US
Mailing Address - Phone:336-612-3434
Mailing Address - Fax:336-612-2120
Practice Address - Street 1:901 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-6012
Practice Address - Country:US
Practice Address - Phone:336-613-6537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-03
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1619543121Medicaid