Healthcare Provider Details

I. General information

NPI: 1578791596
Provider Name (Legal Business Name): MEBANE DRUG STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2009
Last Update Date: 07/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E CLAY ST
MEBANE NC
27302-2434
US

IV. Provider business mailing address

4918 WARFIELD DR
GREENSBORO NC
27406-9350
US

V. Phone/Fax

Practice location:
  • Phone: 919-304-3784
  • Fax:
Mailing address:
  • Phone: 336-392-5857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number10313
License Number StateNC

VIII. Authorized Official

Name: ISAAC BRADY
Title or Position: PRESIDENT/OWNER
Credential:
Phone: 336-392-5857