Provider Demographics
NPI:1881722544
Name:SPRUCE PINE PHARMACY INC
Entity type:Organization
Organization Name:SPRUCE PINE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:PROFFITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-765-2281
Mailing Address - Street 1:431 ALTAPASS HWY
Mailing Address - Street 2:
Mailing Address - City:SPRUCE PINE
Mailing Address - State:NC
Mailing Address - Zip Code:28777-3010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:431 ALTAPASS HWY
Practice Address - Street 2:
Practice Address - City:SPRUCE PINE
Practice Address - State:NC
Practice Address - Zip Code:28777-3010
Practice Address - Country:US
Practice Address - Phone:828-765-2281
Practice Address - Fax:828-765-6215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC006683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0615161Medicaid
3411244OtherOTHER ID NUMBER
NC0315161Medicaid
3411244OtherOTHER ID NUMBER-COMMERCIAL NUMBER