Provider Demographics
NPI:1730194333
Name:COASTAL CARE PHARMACY INC
Entity type:Organization
Organization Name:COASTAL CARE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FLETCHER
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:252-726-0279
Mailing Address - Street 1:278 HWY 24
Mailing Address - Street 2:STE M
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557
Mailing Address - Country:US
Mailing Address - Phone:252-726-0279
Mailing Address - Fax:252-726-0792
Practice Address - Street 1:278 HWY 24
Practice Address - Street 2:STE M
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557
Practice Address - Country:US
Practice Address - Phone:252-726-0279
Practice Address - Fax:252-726-0792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
NC083843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0165422Medicaid
2070226OtherPK
NC0165422Medicaid
540622001Medicare ID - Type Unspecified