Provider Demographics
NPI:1861613994
Name:ETOWAH PHARMACY, INC.
Entity type:Organization
Organization Name:ETOWAH PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LONDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-890-0022
Mailing Address - Street 1:6527 BREVARD ROAD
Mailing Address - Street 2:
Mailing Address - City:ETOWAH
Mailing Address - State:NC
Mailing Address - Zip Code:28729-0351
Mailing Address - Country:US
Mailing Address - Phone:828-890-0022
Mailing Address - Fax:
Practice Address - Street 1:6527 BREVARD RD.
Practice Address - Street 2:
Practice Address - City:ETOWAH
Practice Address - State:NC
Practice Address - Zip Code:28729-0351
Practice Address - Country:US
Practice Address - Phone:828-890-0022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NC75803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0445626Medicaid
NC3437894OtherNABP
NC7580OtherPHARMACY PERMIT NUMBER
NCBE6792077OtherDEA
NC7580OtherPHARMACY PERMIT NUMBER
NC3437894OtherNABP