Provider Demographics
NPI:1720190770
Name:KERR DRUG INC A DELAWARE COMPANY
Entity Type:Organization
Organization Name:KERR DRUG INC A DELAWARE COMPANY
Other - Org Name:KERR DRUG 309
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DICK
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:336-621-2962
Mailing Address - Street 1:1435 E CONE BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-4533
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1435 E CONE BLVD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-4533
Practice Address - Country:US
Practice Address - Phone:336-621-2962
Practice Address - Fax:336-533-0033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6862333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0417575Medicaid
3433377OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NC0417575Medicaid