Provider Demographics
NPI:1205974961
Name:MOUNT GILEAD LLC
Entity type:Organization
Organization Name:MOUNT GILEAD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:ANIL
Authorized Official - Middle Name:K
Authorized Official - Last Name:CHINAPAGA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:910-439-6541
Mailing Address - Street 1:PO BOX 248
Mailing Address - Street 2:116 SOUTH MAIN STREET
Mailing Address - City:MOUNT GILEAD
Mailing Address - State:NC
Mailing Address - Zip Code:27306-0248
Mailing Address - Country:US
Mailing Address - Phone:910-439-6541
Mailing Address - Fax:910-439-5723
Practice Address - Street 1:116 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:MOUNT GILEAD
Practice Address - State:NC
Practice Address - Zip Code:27306-0248
Practice Address - Country:US
Practice Address - Phone:910-439-6541
Practice Address - Fax:910-439-5723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22173336C0003X
333600000X
NC02217333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2066533OtherPK
NC0625053Medicaid
1065000001Medicare NSC
1065000001Medicare NSC