Provider Demographics
NPI:1760927602
Name:PREMIER PHARMACY AND WELLNESS CENTER
Entity Type:Organization
Organization Name:PREMIER PHARMACY AND WELLNESS CENTER
Other - Org Name:PREMIER PHARMACY AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTEZ
Authorized Official - Middle Name:LAVARD
Authorized Official - Last Name:PRINCE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:704-496-9182
Mailing Address - Street 1:3010 MONROE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-7532
Mailing Address - Country:US
Mailing Address - Phone:704-496-9182
Mailing Address - Fax:704-496-9903
Practice Address - Street 1:2557 W FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-1249
Practice Address - Country:US
Practice Address - Phone:704-496-9182
Practice Address - Fax:704-496-9903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-02
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13131333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2167029OtherPK