Healthcare Provider Details

I. General information

NPI: 1366468225
Provider Name (Legal Business Name): TALL OAKS PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 09/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

798 OAK RIDGE FARM HWY STE C
MOORESVILLE NC
28115-7923
US

IV. Provider business mailing address

8703 STUDLEY RD STE B
MECHANICSVILLE VA
23116-2016
US

V. Phone/Fax

Practice location:
  • Phone: 704-658-9814
  • Fax: 704-658-0721
Mailing address:
  • Phone: 704-658-9814
  • Fax: 704-658-0721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number09273
License Number StateNC

VIII. Authorized Official

Name: LARRY CARRUTH
Title or Position: OWNER
Credential: RPH
Phone: 704-658-9814