Provider Demographics
NPI:1639111453
Name:INNES ST DRUG COMPANY INC
Entity Type:Organization
Organization Name:INNES ST DRUG COMPANY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-633-4521
Mailing Address - Street 1:PO BOX 4065
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28145-4065
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-4942
Practice Address - Country:US
Practice Address - Phone:704-633-4521
Practice Address - Fax:704-633-1893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC05608333600000X
3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3410672OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NC0805465Medicaid
0265260002Medicare ID - Type Unspecified