Provider Demographics
NPI:1649363870
Name:PITTSBORO DISCOUNT DRUG, INC
Entity type:Organization
Organization Name:PITTSBORO DISCOUNT DRUG, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:VASSIE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:919-542-7283
Mailing Address - Street 1:PO BOX 1787
Mailing Address - Street 2:
Mailing Address - City:PITTSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27312-1783
Mailing Address - Country:US
Mailing Address - Phone:919-542-7283
Mailing Address - Fax:919-542-7220
Practice Address - Street 1:628 EAST ST
Practice Address - Street 2:
Practice Address - City:PITTSBORO
Practice Address - State:NC
Practice Address - Zip Code:27312-9474
Practice Address - Country:US
Practice Address - Phone:919-542-7283
Practice Address - Fax:919-542-7220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
NC089473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2067696OtherPK
NC0195257Medicaid
NC0195257Medicaid