Healthcare Provider Details

I. General information

NPI: 1164672093
Provider Name (Legal Business Name): REALO DISCOUNT DRUG STORES OF PINK HILL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2008
Last Update Date: 06/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 W BROADWAY ST
PINK HILL NC
28572-7998
US

IV. Provider business mailing address

PO BOX 609
PINK HILL NC
28572-0609
US

V. Phone/Fax

Practice location:
  • Phone: 252-568-3161
  • Fax: 252-568-2339
Mailing address:
  • Phone: 252-568-3161
  • Fax: 252-568-2339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number7025
License Number StateNC

VIII. Authorized Official

Name: MR. MICHAEL GREGG WIGGINS JR.
Title or Position: PHARMACIST-MANAGER
Credential: R.PH.
Phone: 252-568-3161