MEDICARE: PREMIER PHARMACY AND WELLNESS CENTER LLC

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	3336L0003X	Long Term Care Pharmacy

General Provider Information

NPI Number	:	1982236584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER PHARMACY AND WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	3010 MONROE RD STE 101
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-7533
Country	:	US
Telephone Number	:	704-496-9182
Fax Number	:	704-496-9903

Provider Business Practice Location Address
First Line	:	3010 MONROE RD STE 101
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-7533
Country	:	US
Telephone Number	:	704-496-9182
Fax Number	:	704-496-9903

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MARTEZ LAVARD PRINCE
Credential	:	PHARMD.
Telephone Number	:	704-496-9182

Provider Enumeration Date	:	02/11/2020
Last Update Date	:	07/13/2022

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