Provider Demographics
NPI:1881996114
Name:KERNERSVILLE PHARMACY LLC
Entity type:Organization
Organization Name:KERNERSVILLE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:OAKLEY
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:336-497-4511
Mailing Address - Street 1:841 OLD WINSTON RD
Mailing Address - Street 2:STE 90
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-7144
Mailing Address - Country:US
Mailing Address - Phone:336-497-4511
Mailing Address - Fax:
Practice Address - Street 1:841 OLD WINSTON RD
Practice Address - Street 2:STE 90
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-7144
Practice Address - Country:US
Practice Address - Phone:336-497-4511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC105213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0347780Medicaid