Provider Demographics
NPI:1912949710
Name:INNES STREET DRUG COMPANY
Entity Type:Organization
Organization Name:INNES STREET DRUG COMPANY
Other - Org Name:INNES STREET DRUG COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-636-1712
Mailing Address - Street 1:PO BOX 4065
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28145-4065
Mailing Address - Country:US
Mailing Address - Phone:704-633-4521
Mailing Address - Fax:704-633-1893
Practice Address - Street 1:1706 W INNES ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2552
Practice Address - Country:US
Practice Address - Phone:704-636-1712
Practice Address - Fax:704-637-0324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC056093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0805473Medicaid
2067260OtherPK