Provider Demographics
NPI:1720173396
Name:PEMBROKE DRUG CENTER
Entity Type:Organization
Organization Name:PEMBROKE DRUG CENTER
Other - Org Name:HEALTHKEEPERZ
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:B
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-522-0001
Mailing Address - Street 1:P.O. BOX 1030
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-1030
Mailing Address - Country:US
Mailing Address - Phone:910-522-0009
Mailing Address - Fax:910-521-5654
Practice Address - Street 1:4155 FERNCREEK DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-2581
Practice Address - Country:US
Practice Address - Phone:910-485-7131
Practice Address - Fax:910-485-7132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7704496Medicaid
NC7704496Medicaid