Provider Demographics
NPI:1891762134
Name:CLINTON PHARMACY LLC
Entity Type:Organization
Organization Name:CLINTON PHARMACY LLC
Other - Org Name:CLINTON DRUG COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-385-1602
Mailing Address - Street 1:307 BEAMAN ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328-2907
Mailing Address - Country:US
Mailing Address - Phone:910-592-8444
Mailing Address - Fax:910-592-6505
Practice Address - Street 1:307 BEAMAN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-2907
Practice Address - Country:US
Practice Address - Phone:910-592-8444
Practice Address - Fax:910-592-6505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
NC117783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2144114OtherPK
NC0825281Medicaid
NC11778OtherNC STATE BOARD OF PHARMACY LIC.