Healthcare Provider Details

I. General information

NPI: 1487755807
Provider Name (Legal Business Name): WALNUT COVE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 10/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 N MAIN ST
WALNUT COVE NC
27052-9200
US

IV. Provider business mailing address

PO BOX 537
WALNUT COVE NC
27052-0537
US

V. Phone/Fax

Practice location:
  • Phone: 336-591-7171
  • Fax: 336-591-7936
Mailing address:
  • Phone: 336-591-7171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number5086
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: RONALD WATTS
Title or Position: OWNER
Credential: RPH
Phone: 336-591-7171