Provider Demographics
NPI:1265707228
Name:FAYETTEVILLE FAMILY MEDICAL CARE, PA
Entity type:Organization
Organization Name:FAYETTEVILLE FAMILY MEDICAL CARE, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:M
Authorized Official - Last Name:KUGLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-323-1718
Mailing Address - Street 1:1307 AVON ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4423
Mailing Address - Country:US
Mailing Address - Phone:910-323-1718
Mailing Address - Fax:910-323-3834
Practice Address - Street 1:1307 AVON ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4423
Practice Address - Country:US
Practice Address - Phone:910-323-1718
Practice Address - Fax:910-323-3834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC077873336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC048YUOtherBCBS