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General NPI Number Information
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NPI Number | 1649528613
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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 | 08/24/2012
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Last Update Date | 08/24/2012
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Provider Practice Location Address
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Address Line | 101 S BOND ST
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City | ROWLAND
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State | NC
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Zip | 28383-9639
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Country | US
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Telephone | 910-422-3774
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Fax | 910-422-3752
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Provider Business Mailing Address
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Address Line | PO BOX 2816
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City | PEMBROKE
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State | NC
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Zip | 28372-2816
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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 | DR. JUSTIN DANIEL
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Credential | PHARMD
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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 | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 08381
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License Number State | NC
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