=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376176628
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREEN HILL 124 INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2020
-----------------------------------------------------
Last Update Date | 06/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 124 TRADE CT STE B
-----------------------------------------------------
City | MOORESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28117-5548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-997-3176
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2014 PIN HOOK RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28215-8910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-518-7560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY MANAGER
-----------------------------------------------------
Name | AESHA VORA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-997-3176
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------