Provider Demographics
NPI:1659448371
Name:SOUTHERN PINES PRESCRIPTION SHOPPE
Entity Type:Organization
Organization Name:SOUTHERN PINES PRESCRIPTION SHOPPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:MCCLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-692-7467
Mailing Address - Street 1:1902 N SANDHILLS BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:NC
Mailing Address - Zip Code:28315-2347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1902 N SANDHILLS BLVD STE B
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:NC
Practice Address - Zip Code:28315-2347
Practice Address - Country:US
Practice Address - Phone:910-692-7467
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC075853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7703459Medicaid
NC0355190001Medicare ID - Type Unspecified