Provider Demographics
NPI:1790041440
Name:COROLLA PHARMACY, INC
Entity Type:Organization
Organization Name:COROLLA PHARMACY, INC
Other - Org Name:TODD'S PHARMACY OF CURRITUCK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST-MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:TATUM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:252-232-0278
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:MOYOCK
Mailing Address - State:NC
Mailing Address - Zip Code:27958-0520
Mailing Address - Country:US
Mailing Address - Phone:252-232-0278
Mailing Address - Fax:252-435-4063
Practice Address - Street 1:532 CARATOKE HWY STE A
Practice Address - Street 2:
Practice Address - City:MOYOCK
Practice Address - State:NC
Practice Address - Zip Code:27958-8740
Practice Address - Country:US
Practice Address - Phone:252-232-0278
Practice Address - Fax:252-435-4063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-06
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC75823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0275073Medicaid
NC0275073Medicaid