Provider Demographics
NPI:1528089463
Name:PHARMACY LAND
Entity type:Organization
Organization Name:PHARMACY LAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:B
Authorized Official - Last Name:LAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-635-6450
Mailing Address - Street 1:137 N FIELDCREST RD
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-3947
Mailing Address - Country:US
Mailing Address - Phone:336-635-6450
Mailing Address - Fax:336-635-6540
Practice Address - Street 1:137 N FIELDCREST RD
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-3947
Practice Address - Country:US
Practice Address - Phone:336-635-6450
Practice Address - Fax:336-635-6540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC056513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0795658Medicaid
NC1262690001Medicare NSC