Provider Demographics
NPI:1821258807
Name:BREVARD DRUG COMPANY LLC
Entity Type:Organization
Organization Name:BREVARD DRUG COMPANY LLC
Other - Org Name:BREVARD DRUG COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-883-9757
Mailing Address - Street 1:518 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BREVARD
Mailing Address - State:NC
Mailing Address - Zip Code:28712-4438
Mailing Address - Country:US
Mailing Address - Phone:828-883-9757
Mailing Address - Fax:828-883-2156
Practice Address - Street 1:518 S BROAD ST
Practice Address - Street 2:
Practice Address - City:BREVARD
Practice Address - State:NC
Practice Address - Zip Code:28712-4438
Practice Address - Country:US
Practice Address - Phone:828-883-9757
Practice Address - Fax:828-883-2156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-12
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC104093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3411484OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NC0885294Medicaid