Basic Information
| Provider Information | |||||||||
| NPI: | 1013162312 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH VILLAGE PHARMACY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1493 MAIN ST | ||||||||
| Address2: | P.O. BOX 1209 | ||||||||
| City: | YANCEYVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273798793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366944104 | ||||||||
| FaxNumber: | 3366945823 | ||||||||
| Practice Location | |||||||||
| Address1: | 1493 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | YANCEYVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273798793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366944104 | ||||||||
| FaxNumber: | 3366945823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2008 | ||||||||
| LastUpdateDate: | 12/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | MASSENGILL | ||||||||
| AuthorizedOfficialFirstName: | HUBERT | ||||||||
| AuthorizedOfficialMiddleName: | VERNON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3366944104 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | RPH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 03238 | NC | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 0175125 | 05 | NC | MEDICAID |