Provider Demographics
NPI:1750486510
Name:COMMUNITY PHARMACY OF VALE LLC
Entity Type:Organization
Organization Name:COMMUNITY PHARMACY OF VALE LLC
Other - Org Name:THE DRUG STORE - VALE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-904-3287
Mailing Address - Street 1:9576 NC HWY 10 W
Mailing Address - Street 2:
Mailing Address - City:VALE
Mailing Address - State:NC
Mailing Address - Zip Code:28168
Mailing Address - Country:US
Mailing Address - Phone:704-462-0226
Mailing Address - Fax:704-462-0229
Practice Address - Street 1:9576 NC HWY 10 W
Practice Address - Street 2:
Practice Address - City:VALE
Practice Address - State:NC
Practice Address - Zip Code:28168
Practice Address - Country:US
Practice Address - Phone:704-462-0226
Practice Address - Fax:704-462-0229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NC120643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2147412OtherPK
NC0186299Medicaid
3406635OtherNCPDP PROVIDER IDENTIFICATION NUMBER