MEDICARE: ELM CITY PHARMACY 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	04043	NC
2	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)	004043	NC
3	335E00000X	Prosthetic/Orthotic Supplier	004043	NC
4	332B00000X	Durable Medical Equipment & Medical Supplies	4043	NC
5	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)	4043	NC
6	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0387E	OTHER	NC	BLUE CROSS
3	3405924	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1871691741
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELM CITY PHARMACY INC

Provider Business Mailing Address
First Line	:	PO BOX 637
Second Line	:
City	:	ELM CITY
State	:	NC
Zip	:	27822-0637
Country	:	US
Telephone Number	:	252-236-4664
Fax Number	:	252-236-3078

Provider Business Practice Location Address
First Line	:	118 E MAIN ST
Second Line	:
City	:	ELM CITY
State	:	NC
Zip	:	27822-0637
Country	:	US
Telephone Number	:	252-236-4664
Fax Number	:	252-236-3078

Authorized Official
Title or Position	:	PRESIDENT PHARMACIST
Name	:	MARVIN RUSSELL COWAN
Credential	:	RPH
Telephone Number	:	252-236-4664

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	03/27/2008

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Directions to “ELM CITY PHARMACY INC ” Practice Location

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