Basic Information
| Provider Information | |||||||||
| NPI: | 1295903656 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI COUNTY COMMUNITY HEALTH COUNCIL INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16526 NC HIGHWAY 87 W | ||||||||
| Address2: | |||||||||
| City: | TAR HEEL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283928608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108725722 | ||||||||
| FaxNumber: | 9108725711 | ||||||||
| Practice Location | |||||||||
| Address1: | 16526 NC HIGHWAY 87 W | ||||||||
| Address2: | |||||||||
| City: | TAR HEEL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283928608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108725720 | ||||||||
| FaxNumber: | 9108723711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2008 | ||||||||
| LastUpdateDate: | 01/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | HARGROVE | ||||||||
| AuthorizedOfficialFirstName: | CHASITY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIR OF PHARMACY | ||||||||
| AuthorizedOfficialTelephone: | 9105677119 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHARMD | ||||||||
| NPICertificationDate: | 01/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | N | Suppliers | Pharmacy | Clinic Pharmacy | 3336C0003X | 10010 | NC | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 344001B | 05 | NC | MEDICAID | 3410494 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |