Provider Demographics
NPI:1548679749
Name:TRIAD ADULT AND PEDIATRIC MED-GCH WENDOVER PHARMACY
Entity type:Organization
Organization Name:TRIAD ADULT AND PEDIATRIC MED-GCH WENDOVER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMBETH
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:336-355-9908
Mailing Address - Street 1:1046 E WENDOVER AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-6712
Mailing Address - Country:US
Mailing Address - Phone:336-355-9908
Mailing Address - Fax:
Practice Address - Street 1:1046 E WENDOVER AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6712
Practice Address - Country:US
Practice Address - Phone:336-355-9908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRIAD ADULT AND PEDIATRIC MEDICINE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-13
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC113853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC344047BMedicaid
3460588OtherNABP