MEDICARE: EGB ENTERPRISES 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	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	335E00000X	Prosthetic/Orthotic Supplier
4	3336C0003X	Community/Retail Pharmacy	03991	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2068421	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669555603
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EGB ENTERPRISES INC

Provider Business Mailing Address
First Line	:	PO BOX 148
Second Line	:	PO
City	:	LAKE WACCAMAW
State	:	NC
Zip	:	28450-0148
Country	:	US
Telephone Number	:	910-646-3400
Fax Number	:	910-646-3400

Provider Business Practice Location Address
First Line	:	108 OLD E HWY 74/76
Second Line	:
City	:	LAKE WACCAMAW
State	:	NC
Zip	:	28450-0148
Country	:	US
Telephone Number	:	910-646-3400
Fax Number	:	910-646-4056

Authorized Official
Title or Position	:	PRES PHCST
Name	:	EUGENE BROWN
Credential	:
Telephone Number	:	910-646-3400

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	12/08/2016

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