Provider Demographics
NPI:1750536694
Name:FARMVILLE DISCOUNT DRUG, INC
Entity type:Organization
Organization Name:FARMVILLE DISCOUNT DRUG, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:CROCKER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:252-753-2093
Mailing Address - Street 1:PO BOX 690
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27828-0690
Mailing Address - Country:US
Mailing Address - Phone:252-753-2093
Mailing Address - Fax:
Practice Address - Street 1:3708 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:NC
Practice Address - Zip Code:27828-1499
Practice Address - Country:US
Practice Address - Phone:252-753-2093
Practice Address - Fax:252-753-2499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0745224Medicaid
NC2801165OtherMEDICARE MASS IMMUNIZATION ROSTER
NC0151330001Medicare NSC