Basic Information
Provider Information | |||||||||
NPI: | 1275549925 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HOT SPRINGS HEALTH PROGRAM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LAUREL MEDICAL CENTER PHARMACY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 69 | ||||||||
Address2: |   | ||||||||
City: | MARSHALL | ||||||||
State: | NC | ||||||||
PostalCode: | 287530069 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8286490800 | ||||||||
FaxNumber: | 8286491032 | ||||||||
Practice Location | |||||||||
Address1: | 80 GUNTERTOWN RD | ||||||||
Address2: |   | ||||||||
City: | MARSHALL | ||||||||
State: | NC | ||||||||
PostalCode: | 287537806 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8286562611 | ||||||||
FaxNumber: | 8286569434 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/01/2006 | ||||||||
LastUpdateDate: | 02/12/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DEMPSEY | ||||||||
AuthorizedOfficialFirstName: | PAUL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PHCY DIR | ||||||||
AuthorizedOfficialTelephone: | 8286490800 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHARM D | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | 03007 | NC | Y |   | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 3424164 | 01 |   | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER | 0575274 | 05 | NC |   | MEDICAID |