Provider Demographics
NPI:1841660826
Name:ROCK DRUG OF VALDESE, LLC
Entity type:Organization
Organization Name:ROCK DRUG OF VALDESE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER, LLC
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:828-879-2415
Mailing Address - Street 1:240 MAIN ST W
Mailing Address - Street 2:
Mailing Address - City:VALDESE
Mailing Address - State:NC
Mailing Address - Zip Code:28690-2835
Mailing Address - Country:US
Mailing Address - Phone:828-874-2415
Mailing Address - Fax:828-874-8915
Practice Address - Street 1:240 MAIN ST W
Practice Address - Street 2:
Practice Address - City:VALDESE
Practice Address - State:NC
Practice Address - Zip Code:28690-2835
Practice Address - Country:US
Practice Address - Phone:828-874-2415
Practice Address - Fax:828-874-8915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-02
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC110943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1962584755Medicaid
NC6699940001Medicare NSC