Healthcare Provider Details

I. General information

NPI: 1871691741
Provider Name (Legal Business Name): ELM CITY PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 03/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 E MAIN ST
ELM CITY NC
27822-0637
US

IV. Provider business mailing address

PO BOX 637
ELM CITY NC
27822-0637
US

V. Phone/Fax

Practice location:
  • Phone: 252-236-4664
  • Fax: 252-236-3078
Mailing address:
  • Phone: 252-236-4664
  • Fax: 252-236-3078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number4043
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number004043
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number4043
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number04043
License Number StateNC
# 5
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number004043
License Number StateNC

VIII. Authorized Official

Name: MARVIN RUSSELL COWAN
Title or Position: PRESIDENT PHARMACIST
Credential: RPH
Phone: 252-236-4664