Provider Demographics
NPI:1720386188
Name:MECKLENBURG COUNTY
Entity Type:Organization
Organization Name:MECKLENBURG COUNTY
Other - Org Name:MECKLENBURG COUNTY HEALTH DEPT - SOUTHEAST CAMPUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAYNARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:980-579-0671
Mailing Address - Street 1:249 BILLINGSLEY ROAD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1003
Mailing Address - Country:US
Mailing Address - Phone:980-314-9087
Mailing Address - Fax:704-432-1105
Practice Address - Street 1:249 BILLINGSLEY ROAD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1003
Practice Address - Country:US
Practice Address - Phone:980-314-9087
Practice Address - Fax:704-432-1105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-09
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC062403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1720386188Medicaid
3458519OtherNCPDP PROVIDER IDENTIFICATION NUMBER