Provider Demographics
NPI:1831272566
Name:ELM CITY PHARMACY INC
Entity type:Organization
Organization Name:ELM CITY PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:COWAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:252-236-4664
Mailing Address - Street 1:PO BOX 637
Mailing Address - Street 2:
Mailing Address - City:ELM CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27822-0637
Mailing Address - Country:US
Mailing Address - Phone:252-236-4664
Mailing Address - Fax:252-236-3078
Practice Address - Street 1:118 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:ELM CITY
Practice Address - State:NC
Practice Address - Zip Code:27822
Practice Address - Country:US
Practice Address - Phone:252-236-4664
Practice Address - Fax:252-236-3078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC04043332B00000X, 332BP3500X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0985259Medicaid
NC0387EOtherBLUE CROSS BLUE SHIELD
NC7700546Medicaid
NC7700546Medicaid
NC0387EOtherBLUE CROSS BLUE SHIELD