=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265155220
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRUNSWICK CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2022
-----------------------------------------------------
Last Update Date | 09/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 925 SEASIDE RD. SW SUITE 17
-----------------------------------------------------
City | OCEAN ISLE BEACH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28469
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-575-3742
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 925 SEASIDE RD. SW SUITE 17
-----------------------------------------------------
City | OCEAN ISLE BEACH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28469
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-575-3742
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY MANAGER
-----------------------------------------------------
Name | ERIC DIVENANZO
-----------------------------------------------------
Credential | PHARM D
-----------------------------------------------------
Telephone | 910-575-3742
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------