Provider Demographics
NPI:1710062005
Name:GRACA INC
Entity Type:Organization
Organization Name:GRACA INC
Other - Org Name:COMMUNITY CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDSTON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:940-754-5857
Mailing Address - Street 1:PO BOX 1778
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-1778
Mailing Address - Country:US
Mailing Address - Phone:252-331-2965
Mailing Address - Fax:252-335-0329
Practice Address - Street 1:143 ROSEDALE DR
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-9810
Practice Address - Country:US
Practice Address - Phone:252-331-2965
Practice Address - Fax:252-335-0329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC091913336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3404732OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NC7704429Medicaid
3404732OtherNCPDP PROVIDER IDENTIFICATION NUMBER