Healthcare Provider Details

I. General information

NPI: 1780766576
Provider Name (Legal Business Name): SAM'S DRUG STORE OF ROBESON CO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 05/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 SEASIDE RD SW UNIT 1
OCEAN ISLE BEACH NC
28469-6152
US

IV. Provider business mailing address

925 SEASIDE RD SW UNIT 1
OCEAN ISLE BEACH NC
28469-6152
US

V. Phone/Fax

Practice location:
  • Phone: 910-774-4600
  • Fax: 910-739-7207
Mailing address:
  • Phone: 910-774-4600
  • Fax: 910-739-7207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number09819
License Number StateNC

VIII. Authorized Official

Name: DR. WESLEY WATERS III
Title or Position: PRESIDENT
Credential: PHARM-D/ RPH
Phone: 910-774-4600