Provider Demographics
NPI:1841581550
Name:ELIZABETH CITY STATE UNIVERSITY STUDENT HEALTH SERVICES PHARMACY
Entity type:Organization
Organization Name:ELIZABETH CITY STATE UNIVERSITY STUDENT HEALTH SERVICES PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCOY-DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN-BSN
Authorized Official - Phone:252-335-3268
Mailing Address - Street 1:1704 WEEKSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-7977
Mailing Address - Country:US
Mailing Address - Phone:252-335-3267
Mailing Address - Fax:252-335-3269
Practice Address - Street 1:1704 WEEKSVILLE RD
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-7977
Practice Address - Country:US
Practice Address - Phone:252-335-3267
Practice Address - Fax:252-335-3269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC09433261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service