Provider Demographics
NPI:1902084700
Name:RICETTA RX NORTH CAROLINA, LLC.
Entity Type:Organization
Organization Name:RICETTA RX NORTH CAROLINA, LLC.
Other - Org Name:SOUTHERN PHARMACY SERVICES WINSTON-SALEM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:NOPED
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:336-577-3971
Mailing Address - Street 1:556 ARBOR HILL RD
Mailing Address - Street 2:SUITE J
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-3375
Mailing Address - Country:US
Mailing Address - Phone:866-768-8479
Mailing Address - Fax:866-928-3983
Practice Address - Street 1:556 ARBOR HILL RD
Practice Address - Street 2:SUITE J
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-3375
Practice Address - Country:US
Practice Address - Phone:866-768-8479
Practice Address - Fax:866-928-3983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0347380Medicaid
6369250001Medicare NSC