Provider Demographics
NPI:1821387911
Name:GUARDIAN PHARMACY OF EASTERN NC, LLC
Entity Type:Organization
Organization Name:GUARDIAN PHARMACY OF EASTERN NC, LLC
Other - Org Name:SOUTHERN PHARMACY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:TERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-768-8479
Mailing Address - Street 1:DEPT # 2435 GUARDIAN PHARMACY OF EASTERN NC
Mailing Address - Street 2:P.O. BOX 11407
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-0001
Mailing Address - Country:US
Mailing Address - Phone:404-810-0089
Mailing Address - Fax:404-810-0094
Practice Address - Street 1:4459 TARHEEL DR
Practice Address - Street 2:
Practice Address - City:PINK HILL
Practice Address - State:NC
Practice Address - Zip Code:28572-9649
Practice Address - Country:US
Practice Address - Phone:252-568-9945
Practice Address - Fax:866-928-3983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-30
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
NC109663336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2130223OtherPK
VA1821387911Medicaid
NC1821387911Medicaid
SC7N0965Medicaid