Provider Demographics
NPI:1801205018
Name:TRIAD ADULT AND PEDIATRIC MED- GREENSBORO PHARMACY
Entity Type:Organization
Organization Name:TRIAD ADULT AND PEDIATRIC MED- GREENSBORO PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:HALLISEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:336-355-9912
Mailing Address - Street 1:1002 S EUGENE ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-1308
Mailing Address - Country:US
Mailing Address - Phone:336-355-9909
Mailing Address - Fax:336-676-6170
Practice Address - Street 1:1002 S EUGENE ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-1308
Practice Address - Country:US
Practice Address - Phone:336-355-9909
Practice Address - Fax:336-676-6170
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRIAD ADULT AND PEDIATRIC MEDICINE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-13
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1067103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC344045BMedicaid