Provider Demographics
NPI:1790122463
Name:SOUTHERN PINES PRESCRIPTION SHOP INC
Entity Type:Organization
Organization Name:SOUTHERN PINES PRESCRIPTION SHOP INC
Other - Org Name:MCCLAIN DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-315-4445
Mailing Address - Street 1:735 S BENNETT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-5921
Mailing Address - Country:US
Mailing Address - Phone:910-246-9355
Mailing Address - Fax:910-246-1755
Practice Address - Street 1:735 S BENNETT ST
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-5921
Practice Address - Country:US
Practice Address - Phone:910-246-9355
Practice Address - Fax:910-246-1755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-04
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC115593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140593OtherPK