=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336222801
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOORESVILLE PHARMACY EAST LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 594 N MAIN ST
-----------------------------------------------------
City | MOORESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28115-2328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-799-6870
-----------------------------------------------------
Fax | 704-799-6871
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 594 N MAIN ST
-----------------------------------------------------
City | MOORESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28115-2328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-799-6870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PHARMACIST
-----------------------------------------------------
Name | DR. GAVIN MICHAEL HOUCHINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-799-6870
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 7707
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | 07707
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------