Healthcare Provider Details

I. General information

NPI: 1396470209
Provider Name (Legal Business Name): OLD MONROE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2022
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4514 OLD MONROE RD STE A
INDIAN TRAIL NC
28079-5308
US

IV. Provider business mailing address

4514 OLD MONROE RD STE A
INDIAN TRAIL NC
28079-5308
US

V. Phone/Fax

Practice location:
  • Phone: 704-831-7895
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: GLENN SHIELDS
Title or Position: PHARMACY MANAGER
Credential:
Phone: 704-301-4651