Provider Demographics
NPI:1013319235
Name:WINSTON SALEM STATE UNIVERSITY
Entity Type:Organization
Organization Name:WINSTON SALEM STATE UNIVERSITY
Other - Org Name:WSSU WELLNESS CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:IRBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:3367-509-8814
Mailing Address - Street 1:601 S MARTIN LUTHER KING JR DR
Mailing Address - Street 2:SUITE 244
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27110-0003
Mailing Address - Country:US
Mailing Address - Phone:336-750-3376
Mailing Address - Fax:
Practice Address - Street 1:601 S MARTIN LUTHER KING JR DR
Practice Address - Street 2:SUITE 244
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27110-0003
Practice Address - Country:US
Practice Address - Phone:336-750-3376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WINSTON SALEM STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-18
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC121253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy