Healthcare Provider Details

I. General information

NPI: 1912013889
Provider Name (Legal Business Name): TABOR CITY MEDICINE MART, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 S MAIN ST
TABOR CITY NC
28463-1904
US

IV. Provider business mailing address

PO BOX 580
TABOR CITY NC
28463-0580
US

V. Phone/Fax

Practice location:
  • Phone: 910-653-4800
  • Fax: 910-653-4915
Mailing address:
  • Phone: 910-653-4800
  • Fax: 910-653-4915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: STERLING G KOONCE
Title or Position: OWNER/PRESIDENT
Credential: RPH
Phone: 910-653-6805