Provider Demographics
NPI:1972894145
Name:COASTAL CARE PHARMACY INC
Entity Type:Organization
Organization Name:COASTAL CARE PHARMACY INC
Other - Org Name:MEDICAL PARK PHARMACY WEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FLETCHER
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-726-0279
Mailing Address - Street 1:278 HWY 24
Mailing Address - Street 2:SUITE M
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-2582
Mailing Address - Country:US
Mailing Address - Phone:252-726-0279
Mailing Address - Fax:252-726-0792
Practice Address - Street 1:278 HWY 24
Practice Address - Street 2:SUITE M
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-2582
Practice Address - Country:US
Practice Address - Phone:252-726-0279
Practice Address - Fax:252-726-0792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-22
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC83843336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0165422Medicaid
NC0165422Medicaid