Provider Demographics
NPI:1922278241
Name:METROLINA PAIN CLINIC DISPENSARY
Entity Type:Organization
Organization Name:METROLINA PAIN CLINIC DISPENSARY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CICELY
Authorized Official - Middle Name:
Authorized Official - Last Name:EASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-935-6063
Mailing Address - Street 1:PO BOX 4688
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33338-4688
Mailing Address - Country:US
Mailing Address - Phone:954-376-7313
Mailing Address - Fax:954-697-0153
Practice Address - Street 1:6300 E INDEPENDENCE BLVD.
Practice Address - Street 2:SUITE B
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212
Practice Address - Country:US
Practice Address - Phone:704-568-9133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHYSICIANS CHOICE DISPENSING SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-03
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13919332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site