Provider Demographics
NPI:1184792327
Name:MEDICINE SHOPPE OF ASHEBORO NC INC
Entity type:Organization
Organization Name:MEDICINE SHOPPE OF ASHEBORO NC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRES AND PHARM MGR
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-625-8650
Mailing Address - Street 1:700 N FAYETTEVILLE ST
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27203-4611
Mailing Address - Country:US
Mailing Address - Phone:336-625-8650
Mailing Address - Fax:336-636-5920
Practice Address - Street 1:700 N FAYETTEVILLE ST
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-4611
Practice Address - Country:US
Practice Address - Phone:336-625-8650
Practice Address - Fax:336-636-5920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC101263336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0765222Medicaid
2068141OtherPK
NC0765222Medicaid