Provider Demographics
NPI:1942201173
Name:FARMVILLE DISCOUNT DRUG, INC.
Entity Type:Organization
Organization Name:FARMVILLE DISCOUNT DRUG, INC.
Other - Org Name:BEST VALUE DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:CROCKER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:252-753-2092
Mailing Address - Street 1:PO BOX 690
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27828-0690
Mailing Address - Country:US
Mailing Address - Phone:252-753-2092
Mailing Address - Fax:252-753-2499
Practice Address - Street 1:3708 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:NC
Practice Address - Zip Code:27828-1465
Practice Address - Country:US
Practice Address - Phone:252-753-2092
Practice Address - Fax:252-753-2499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC03259332B00000X, 3336C0003X, 3336C0004X, 3336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7700071Medicaid
NC6800352Medicaid
NC0745224Medicaid
NC0745224Medicaid
NC3414214Medicare UPIN
NC0151330001Medicare NSC