MEDICARE: LONGS DRUGS OF CHARLOTTE 1 INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336L0003X	Long Term Care Pharmacy
3	3336C0003X	Community/Retail Pharmacy	11837	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2132008	OTHER		PK

General Provider Information

NPI Number	:	1053301242
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONGS DRUGS OF CHARLOTTE 1 INC

Provider Business Mailing Address
First Line	:	PO BOX 602675
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-2675
Country	:	US
Telephone Number	:	704-525-3956
Fax Number	:	704-525-3978

Provider Business Practice Location Address
First Line	:	3039 SOUTH BLVD STE F
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-1866
Country	:	US
Telephone Number	:	704-525-3956
Fax Number	:	704-525-3978

Authorized Official
Title or Position	:	DIRECTOR OF BUSINESS DEVELOPMENT
Name	:	MARSHALL FROST
Credential	:
Telephone Number	:	404-583-6945

Provider Enumeration Date	:	10/27/2005
Last Update Date	:	09/13/2016

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