Provider Demographics
NPI:1720191661
Name:MEDICAL ARTS PHARMACY INC
Entity Type:Organization
Organization Name:MEDICAL ARTS PHARMACY INC
Other - Org Name:MEDICAL ARTS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:252-492-3404
Mailing Address - Street 1:253 RUIN CREEK RD
Mailing Address - Street 2:0
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536
Mailing Address - Country:US
Mailing Address - Phone:252-492-3404
Mailing Address - Fax:252-433-4649
Practice Address - Street 1:253 RUIN CREEK RD
Practice Address - Street 2:0
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536
Practice Address - Country:US
Practice Address - Phone:252-492-3404
Practice Address - Fax:252-433-4649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BC3200X, 333600000X, 3336C0004X
NC027413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0915181Medicaid
NC7701377Medicaid
2066101OtherPK
0806240001Medicare NSC
3407221OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NCAM4167537OtherDEA NUMBER