Provider Demographics
NPI:1790923555
Name:SENIOR CARE PHARMACY LLC
Entity Type:Organization
Organization Name:SENIOR CARE PHARMACY LLC
Other - Org Name:COPPER CREEK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANGER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-246-6510
Mailing Address - Street 1:1207 CREWS RD STE D
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-7582
Mailing Address - Country:US
Mailing Address - Phone:704-246-6510
Mailing Address - Fax:704-246-7775
Practice Address - Street 1:1207 CREWS RD STE D
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-7582
Practice Address - Country:US
Practice Address - Phone:704-246-6510
Practice Address - Fax:704-246-7775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-30
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC102353336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2119183OtherPK
NC0602342Medicaid