Provider Demographics
NPI:1750584769
Name:LEICESTER VILLAGE PHARMACY, LLC
Entity type:Organization
Organization Name:LEICESTER VILLAGE PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:(NMN)
Authorized Official - Last Name:OVERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:R,PH
Authorized Official - Phone:828-683-6727
Mailing Address - Street 1:876 NEW LEICESTER HWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28806-1049
Mailing Address - Country:US
Mailing Address - Phone:828-683-6727
Mailing Address - Fax:828-683-6727
Practice Address - Street 1:876 NEW LEICESTER HWY
Practice Address - Street 2:SUITE 1
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28806-1049
Practice Address - Country:US
Practice Address - Phone:828-683-6727
Practice Address - Fax:828-683-6727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC095373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6042170001Medicare NSC