Provider Demographics
NPI:1740246677
Name:EDEN DRUG, INC.
Entity type:Organization
Organization Name:EDEN DRUG, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:CROUCH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, CPP
Authorized Official - Phone:336-627-4854
Mailing Address - Street 1:103 W STADIUM DR
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-3329
Mailing Address - Country:US
Mailing Address - Phone:336-627-4854
Mailing Address - Fax:336-627-8925
Practice Address - Street 1:103 W STADIUM DR
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-3329
Practice Address - Country:US
Practice Address - Phone:336-627-4854
Practice Address - Fax:336-627-8925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC094583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3420015OtherNCPDP
VA008507139Medicaid
NC0795443Medicaid
VA008507139Medicaid