Provider Demographics
NPI:1710396924
Name:TRIAD ADULT AND PEDIATRIC MEDICINE -HIGH POINT PHCY
Entity Type:Organization
Organization Name:TRIAD ADULT AND PEDIATRIC MEDICINE -HIGH POINT PHCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:HALLISEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:336-355-9912
Mailing Address - Street 1:624 QUAKER LN
Mailing Address - Street 2:100 C
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-3832
Mailing Address - Country:US
Mailing Address - Phone:336-878-6033
Mailing Address - Fax:336-878-6058
Practice Address - Street 1:624 QUAKER LN
Practice Address - Street 2:100 C
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-3832
Practice Address - Country:US
Practice Address - Phone:336-878-6033
Practice Address - Fax:336-878-6058
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRIAD ADULT AND PEDIATRIC MEDICINE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC344044BMedicaid