Basic Information
| Provider Information | |||||||||
| NPI: | 1902561392 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KINSTON COMMUNITY HEALTH CENTER, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KINSTON COMMUNITY PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2278 | ||||||||
| Address2: | |||||||||
| City: | KINSTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285022278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525229800 | ||||||||
| FaxNumber: | 2525239790 | ||||||||
| Practice Location | |||||||||
| Address1: | 324 N QUEEN ST STE A | ||||||||
| Address2: | |||||||||
| City: | KINSTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285014932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525490847 | ||||||||
| FaxNumber: | 2525254876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2021 | ||||||||
| LastUpdateDate: | 08/17/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WALLACE | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | LISA | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2525229800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KINSTON COMMUNITY HEALTH CENTER, INC | ||||||||
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| NPICertificationDate: | 08/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 3336S0011X | N | Suppliers | Pharmacy | Specialty Pharmacy | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.