Provider Demographics
NPI:1790817724
Name:HAZELWOOD PHARMACY INC
Entity type:Organization
Organization Name:HAZELWOOD PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GERALDINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KEENUM JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-456-5481
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:NC
Mailing Address - Zip Code:28738-0247
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:429 HAZELWOOD AVE
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:NC
Practice Address - Zip Code:28786-1946
Practice Address - Country:US
Practice Address - Phone:828-456-5481
Practice Address - Fax:828-452-2120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC040343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3407170OtherOTHER ID NUMBER
3407170OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NC0445049Medicaid