Provider Demographics
NPI:1700925898
Name:MINTZ COASTAL DRUG STORE INC
Entity Type:Organization
Organization Name:MINTZ COASTAL DRUG STORE INC
Other - Org Name:COASTAL DRUG STORE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT, MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:LOU
Authorized Official - Last Name:MINTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-754-6563
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:SHALLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28459-0070
Mailing Address - Country:US
Mailing Address - Phone:910-754-6563
Mailing Address - Fax:
Practice Address - Street 1:4802 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-1863
Practice Address - Country:US
Practice Address - Phone:910-754-6563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC092933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5622960001Medicare NSC