Healthcare Provider Details

I. General information

NPI: 1336445360
Provider Name (Legal Business Name): MEDASSIST OF MECKLENBURG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2011
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E 5TH ST STE 350
CHARLOTTE NC
28202-3031
US

IV. Provider business mailing address

601 E 5TH ST STE 350
CHARLOTTE NC
28202-3031
US

V. Phone/Fax

Practice location:
  • Phone: 704-536-1790
  • Fax: 704-536-9812
Mailing address:
  • Phone: 704-536-1790
  • Fax: 704-536-9812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number7100
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number7100
License Number StateNC

VIII. Authorized Official

Name: MRS. LORI GIANG
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 704-536-9766