Healthcare Provider Details

I. General information

NPI: 1750486510
Provider Name (Legal Business Name): COMMUNITY PHARMACY OF VALE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 01/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9576 NC HWY 10 W
VALE NC
28168
US

IV. Provider business mailing address

9576 NC HWY 10 W
VALE NC
28168
US

V. Phone/Fax

Practice location:
  • Phone: 704-462-0226
  • Fax: 704-462-0229
Mailing address:
  • Phone: 704-462-0226
  • Fax: 704-462-0229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number12064
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2147412
Identifier TypeOTHER
Identifier State
Identifier IssuerPK
# 2
Identifier0186299
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: MARK RICHARDS
Title or Position: OWNER/TREASURER
Credential:
Phone: 704-904-3287