Provider Demographics
NPI:1336222801
Name:MOORESVILLE PHARMACY EAST LLC
Entity Type:Organization
Organization Name:MOORESVILLE PHARMACY EAST LLC
Other - Org Name:HEALTHSMART PHARMACY (EAST)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GAVIN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HOUCHINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-799-6870
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:704-799-6871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7707333600000X
3336C0003X
NC077073336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0497129Medicaid
3438276OtherOTHER ID NUMBER-COMMERCIAL NUMBER
SC7N7707Medicaid
NC7703285Medicaid
NC7703285Medicaid
NC2779618AMedicare PIN
NC7703285Medicaid
NC3986380001Medicare NSC