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General NPI Number Information
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NPI Number | 1013152099
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Entity Type | Organization
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Legal Business Name | OLD MAIN PHARMACY INC
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Dates
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Enumeration Date | 12/05/2008
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Last Update Date | 02/20/2017
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Provider Practice Location Address
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Address Line | 407 W 3RD ST
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City | PEMBROKE
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State | NC
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Zip | 28372-7977
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Country | US
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Telephone | 910-522-5500
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Fax | 910-844-3017
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Provider Business Mailing Address
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Address Line | PO BOX 2639
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City | PEMBROKE
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State | NC
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Zip | 28372-2639
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Country | US
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Telephone | 910-521-5600
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Fax | 910-521-1906
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | JUSTIN DANIEL
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Credential |
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Telephone | 910-521-5600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 11213
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License Number State | NC
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