Healthcare Provider Details

I. General information

NPI: 1154428092
Provider Name (Legal Business Name): COROLLA PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 04/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

532 A CARATOKE HWY
MOYOCK NC
27958
US

IV. Provider business mailing address

PO BOX 520
MOYOCK NC
27958-0520
US

V. Phone/Fax

Practice location:
  • Phone: 252-232-0278
  • Fax: 252-435-4063
Mailing address:
  • Phone:
  • Fax:

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 Number7582
License Number StateNC

VIII. Authorized Official

Name: WILLIAM OWENS
Title or Position: PRES/OWNER
Credential: RPH
Phone: 252-335-2901