Provider Demographics
NPI:1942394358
Name:HOMETOWN DISCOUNT PHARMACY OF GREENVILLE, INC.
Entity Type:Organization
Organization Name:HOMETOWN DISCOUNT PHARMACY OF GREENVILLE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-752-0003
Mailing Address - Street 1:1631 GREENVILLE BLVD SE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-4809
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1631 GREENVILLE BLVD SE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-4809
Practice Address - Country:US
Practice Address - Phone:252-752-0003
Practice Address - Fax:252-752-3145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC084213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3439127OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NC0745894Medicaid
3439127OtherOTHER ID NUMBER
3439127OtherOTHER ID NUMBER