Provider Demographics
NPI:1780848804
Name:HEALTHSMART PHARMACY LLC
Entity Type:Organization
Organization Name:HEALTHSMART PHARMACY LLC
Other - Org Name:HEALTHSMART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:BALOG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-906-0281
Mailing Address - Street 1:108 LEANING OAK DR
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117
Mailing Address - Country:US
Mailing Address - Phone:704-658-1184
Mailing Address - Fax:794-658-1184
Practice Address - Street 1:108 LEANING OAK DR
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117
Practice Address - Country:US
Practice Address - Phone:704-658-1184
Practice Address - Fax:794-658-1184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-17
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0497682Medicaid
3411458OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NC0497682Medicaid