Provider Demographics
NPI:1629477377
Name:EICCUA LLC
Entity Type:Organization
Organization Name:EICCUA LLC
Other - Org Name:WILSONVALUE DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:IJEOMA
Authorized Official - Middle Name:
Authorized Official - Last Name:UWAKWE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM/D
Authorized Official - Phone:252-293-4177
Mailing Address - Street 1:404 NASH ST NE
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-3743
Mailing Address - Country:US
Mailing Address - Phone:252-293-4177
Mailing Address - Fax:252-293-4180
Practice Address - Street 1:404 NASH ST NE
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-3743
Practice Address - Country:US
Practice Address - Phone:252-293-4177
Practice Address - Fax:252-293-4180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-19
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC120733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1629477377Medicaid
NC7488720001Medicare NSC