Provider Demographics
NPI:1245707116
Name:MOORESVILLE PHARMACY EAST, LLC
Entity type:Organization
Organization Name:MOORESVILLE PHARMACY EAST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GAVIN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HOUCHINS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:704-799-6872
Mailing Address - Street 1:594 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-2328
Mailing Address - Country:US
Mailing Address - Phone:704-799-6870
Mailing Address - Fax:
Practice Address - Street 1:594 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-2328
Practice Address - Country:US
Practice Address - Phone:704-799-6870
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOORESVILLE PHARMACY EAST LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0497129Medicaid
SC7N7707Medicaid