Healthcare Provider Details

I. General information

NPI: 1801513189
Provider Name (Legal Business Name): TABOR CITY MEDICINE MART, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
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: 910-653-6804
  • Fax: 910-653-4915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: STERLING GRADY KOONCE
Title or Position: OWNER
Credential:
Phone: 910-653-6804