Provider Demographics
NPI:1013152099
Name:OLD MAIN PHARMACY INC
Entity type:Organization
Organization Name:OLD MAIN PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-521-5600
Mailing Address - Street 1:PO BOX 2639
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-2639
Mailing Address - Country:US
Mailing Address - Phone:910-521-5600
Mailing Address - Fax:910-521-1906
Practice Address - Street 1:407 W 3RD ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372-7977
Practice Address - Country:US
Practice Address - Phone:910-522-5500
Practice Address - Fax:910-844-3017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-05
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11213333600000X, 3336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2143626OtherPK
3412842OtherNCPDP PROVIDER IDENTIFICATION NUMBER