Provider Demographics
NPI:1912170507
Name:COMMUNITY PHARMACY OF VALE LLC
Entity Type:Organization
Organization Name:COMMUNITY PHARMACY OF VALE LLC
Other - Org Name:THE DRUG STORE VALE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-735-2556
Mailing Address - Street 1:9576 NC 10 HWY W
Mailing Address - Street 2:
Mailing Address - City:VALE
Mailing Address - State:NC
Mailing Address - Zip Code:28168-9409
Mailing Address - Country:US
Mailing Address - Phone:704-462-0226
Mailing Address - Fax:704-462-0229
Practice Address - Street 1:9576 NC HWY 10W
Practice Address - Street 2:
Practice Address - City:VALE
Practice Address - State:NC
Practice Address - Zip Code:28168-7451
Practice Address - Country:US
Practice Address - Phone:704-462-0226
Practice Address - Fax:704-462-0229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-04
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X
NC09378332BX2000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0186299Medicaid
NC7704939Medicaid
NC7704939Medicaid