Provider Demographics
NPI:1982626552
Name:COLUMBIA PHARMACY INC
Entity Type:Organization
Organization Name:COLUMBIA PHARMACY INC
Other - Org Name:COLUMBIA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTON
Authorized Official - Middle Name:PRENTISS
Authorized Official - Last Name:ONEAL
Authorized Official - Suffix:III
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:252-943-2643
Mailing Address - Street 1:PO BOX 239
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:NC
Mailing Address - Zip Code:27925-0239
Mailing Address - Country:US
Mailing Address - Phone:252-796-2421
Mailing Address - Fax:252-796-1124
Practice Address - Street 1:214 MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:NC
Practice Address - Zip Code:27925
Practice Address - Country:US
Practice Address - Phone:252-796-2421
Practice Address - Fax:252-796-1124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC099003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0895060Medicaid
2069093OtherPK
0591050001Medicare NSC