Healthcare Provider Details

I. General information

NPI: 1760927602
Provider Name (Legal Business Name): PREMIER PHARMACY AND WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2017
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2557 W FRANKLIN BLVD
GASTONIA NC
28052-1249
US

IV. Provider business mailing address

3010 MONROE RD SUITE 101
CHARLOTTE NC
28205-7532
US

V. Phone/Fax

Practice location:
  • Phone: 704-496-9182
  • Fax: 704-496-9903
Mailing address:
  • Phone: 704-496-9182
  • Fax: 704-496-9903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number13131
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MARTEZ LAVARD PRINCE
Title or Position: OWNER
Credential: PHARMD
Phone: 704-496-9182