Healthcare Provider Details

I. General information

NPI: 1588827372
Provider Name (Legal Business Name): GO PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 CHAUNCEY TOWN RD STE B
LAKE WACCAMAW NC
28450-2003
US

IV. Provider business mailing address

PO BOX 479
LAKE WACCAMAW NC
28450-0479
US

V. Phone/Fax

Practice location:
  • Phone: 910-646-6614
  • Fax: 910-646-6615
Mailing address:
  • Phone: 910-646-6614
  • Fax: 910-646-6615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number11191
License Number StateNC

VIII. Authorized Official

Name: BRENTON BYRD
Title or Position: CEO
Credential:
Phone: 910-398-5467