Provider Demographics
NPI:1760579965
Name:WALLACE DRUG CO INC
Entity Type:Organization
Organization Name:WALLACE DRUG CO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:EDGBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MCLEMORE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:910-285-3101
Mailing Address - Street 1:100 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WALLACE
Mailing Address - State:NC
Mailing Address - Zip Code:28466-2902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WALLACE
Practice Address - State:NC
Practice Address - Zip Code:28466-2902
Practice Address - Country:US
Practice Address - Phone:910-285-3101
Practice Address - Fax:910-285-5834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
NC05081333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0315234Medicaid
3426118OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NC0315234Medicaid