Provider Demographics
NPI:1801957675
Name:PENDER MEMORIAL HOSPITAL INC
Entity type:Organization
Organization Name:PENDER MEMORIAL HOSPITAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIR OF PHCY
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLETS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:910-259-0704
Mailing Address - Street 1:507 E FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:BURGAW
Mailing Address - State:NC
Mailing Address - Zip Code:28425-5131
Mailing Address - Country:US
Mailing Address - Phone:910-259-0704
Mailing Address - Fax:910-259-9420
Practice Address - Street 1:507 E FREMONT ST
Practice Address - Street 2:
Practice Address - City:BURGAW
Practice Address - State:NC
Practice Address - Zip Code:28425-5131
Practice Address - Country:US
Practice Address - Phone:910-259-0704
Practice Address - Fax:910-259-9420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC022903336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2065212OtherPK
NC0715078Medicaid