=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447628136
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TARGET PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2015
-----------------------------------------------------
Last Update Date | 09/11/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4841 GROVE BARTON RD
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27613-1900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-785-0335
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4841 GROVE BARTON RD
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27613-1900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-785-0335
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST
-----------------------------------------------------
Name | SUZANNE MONTGOMERY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-844-0697
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 12223
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------