Basic Information
| Provider Information | |||||||||
| NPI: | 1013384668 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HODGES FAMILY PHARMACY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | QWIKMED PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2536 THORNGROVE CT | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283030259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105788592 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 204 WESTWOOD SHOPPING CTR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283141528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106767570 | ||||||||
| FaxNumber: | 9106767572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2015 | ||||||||
| LastUpdateDate: | 05/04/2016 | ||||||||
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| AuthorizedOfficialLastName: | HODGES | ||||||||
| AuthorizedOfficialFirstName: | LEROY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 9105788592 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 12889 | NC | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2158827 | 01 | PK | OTHER | 1013384668 | 05 | NC | MEDICAID |