Healthcare Provider Details

I. General information

NPI: 1013218312
Provider Name (Legal Business Name): EGB ENTERJPRISES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2010
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 E HWY 7476
LAKE WACCAMAW NC
28450
US

IV. Provider business mailing address

108 E HWY 7476
LAKE WACCAMAW NC
28450
US

V. Phone/Fax

Practice location:
  • Phone: 910-646-3400
  • Fax: 910-646-4056
Mailing address:
  • Phone: 910-646-3400
  • Fax: 910-646-4056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number03991
License Number StateNC

VIII. Authorized Official

Name: MR. EUGENE G BROWN JR.
Title or Position: PHARMACIST
Credential: RPH
Phone: 910-646-3400