Provider Demographics
NPI:1063553931
Name:VANCE-WARREN COMPREHENSIVE HEALTH PLAN PHARMACY
Entity type:Organization
Organization Name:VANCE-WARREN COMPREHENSIVE HEALTH PLAN PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:WORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-456-2004
Mailing Address - Street 1:986 MANSON AXTELL ROAD
Mailing Address - Street 2:
Mailing Address - City:MANSON
Mailing Address - State:NC
Mailing Address - Zip Code:27553-0425
Mailing Address - Country:US
Mailing Address - Phone:252-456-2181
Mailing Address - Fax:252-456-2115
Practice Address - Street 1:986 MANSON AXTELL ROAD
Practice Address - Street 2:
Practice Address - City:MANSON
Practice Address - State:NC
Practice Address - Zip Code:27553-0425
Practice Address - Country:US
Practice Address - Phone:252-456-2181
Practice Address - Fax:252-456-2115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC03754183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC344566BMedicaid