Basic Information
| Provider Information | |||||||||
| NPI: | 1083269351 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NOVANT HEALTH NEW HANOVER REGIONAL MEDICAL CENTER LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NH NHRMC SPECIALTY PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2250 SHIPYARD BLVD STE 12 | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284038070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106675149 | ||||||||
| FaxNumber: | 9106627777 | ||||||||
| Practice Location | |||||||||
| Address1: | 2250 SHIPYARD BLVD STE 12 | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284038070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106627780 | ||||||||
| FaxNumber: | 9106627777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2019 | ||||||||
| LastUpdateDate: | 02/10/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EDGERTON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF RETAIL & SPECIALTY RX | ||||||||
| AuthorizedOfficialTelephone: | 9106675147 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NOVANT HEALTH NEW HANOVER REGIONAL MEDICAL CENTER LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHARMD | ||||||||
| NPICertificationDate: | 02/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336S0011X | Y | Suppliers | Pharmacy | Specialty Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1083269351 | 05 | NC | MEDICAID |