Provider Demographics
NPI:1013162312
Name:NORTH VILLAGE PHARMACY, INC
Entity Type:Organization
Organization Name:NORTH VILLAGE PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HUBERT
Authorized Official - Middle Name:VERNON
Authorized Official - Last Name:MASSENGILL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:336-694-4104
Mailing Address - Street 1:1493 MAIN ST
Mailing Address - Street 2:P.O. BOX 1209
Mailing Address - City:YANCEYVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27379-8793
Mailing Address - Country:US
Mailing Address - Phone:336-694-4104
Mailing Address - Fax:336-694-5823
Practice Address - Street 1:1493 MAIN ST
Practice Address - Street 2:
Practice Address - City:YANCEYVILLE
Practice Address - State:NC
Practice Address - Zip Code:27379-8793
Practice Address - Country:US
Practice Address - Phone:336-694-4104
Practice Address - Fax:336-694-5823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC032383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0175125Medicaid
NC0175125Medicaid