Provider Demographics
NPI:1457413965
Name:MOORESVILLE PHARMACY LLC
Entity type:Organization
Organization Name:MOORESVILLE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:BALOG
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:704-658-1184
Mailing Address - Street 1:108 LEANING OAK DR
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-6991
Mailing Address - Country:US
Mailing Address - Phone:704-658-1184
Mailing Address - Fax:704-658-1184
Practice Address - Street 1:108 LEANING OAK DR
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-6991
Practice Address - Country:US
Practice Address - Phone:704-658-1184
Practice Address - Fax:704-658-1184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC77803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0497153Medicaid
3438757OtherNCPDP
NC7703604Medicaid
NC7780OtherNORTH CAROLINA BOARD OF PHARMACY
NCBM7264790OtherDEA #
3438757OtherNCPDP
NC7780OtherNORTH CAROLINA BOARD OF PHARMACY