Provider Demographics
NPI:1902848500
Name:MIDELU INCORPORATED
Entity Type:Organization
Organization Name:MIDELU INCORPORATED
Other - Org Name:PLEASANT GARDEN DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:336-963-3317
Mailing Address - Street 1:2593 GREY RABBIT RUN
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27205-8097
Mailing Address - Country:US
Mailing Address - Phone:336-857-1997
Mailing Address - Fax:866-238-8879
Practice Address - Street 1:4822 PLEASANT GARDEN RD
Practice Address - Street 2:
Practice Address - City:PLEASANT GARDEN
Practice Address - State:NC
Practice Address - Zip Code:27313-8253
Practice Address - Country:US
Practice Address - Phone:336-674-5611
Practice Address - Fax:336-674-0995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
NC100313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0415281Medicaid
2066637OtherPK
1087370001Medicare NSC