Provider Demographics
NPI:1750493011
Name:LIBRICK, INC.
Entity Type:Organization
Organization Name:LIBRICK, INC.
Other - Org Name:TRYON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST-MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HENRIKSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:828-859-6615
Mailing Address - Street 1:620 S TRADE ST
Mailing Address - Street 2:
Mailing Address - City:TRYON
Mailing Address - State:NC
Mailing Address - Zip Code:28782-3716
Mailing Address - Country:US
Mailing Address - Phone:828-859-6615
Mailing Address - Fax:828-859-5901
Practice Address - Street 1:620 S TRADE ST
Practice Address - Street 2:
Practice Address - City:TRYON
Practice Address - State:NC
Practice Address - Zip Code:28782-3716
Practice Address - Country:US
Practice Address - Phone:828-859-6615
Practice Address - Fax:828-859-5901
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIBRICK, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-31
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC53333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7700144Medicaid
NC0755074Medicaid
3428023OtherNCPDP
SC7N5333Medicaid
NC7700144Medicaid