Provider Demographics
NPI:1104129998
Name:BLOUNT'S MUTUAL DRUGS, INC.
Entity type:Organization
Organization Name:BLOUNT'S MUTUAL DRUGS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:BLOUNT
Authorized Official - Suffix:SR
Authorized Official - Credentials:RPH
Authorized Official - Phone:252-482-2127
Mailing Address - Street 1:323 S BROAD ST
Mailing Address - Street 2:PO BOX 209
Mailing Address - City:EDENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27932-1933
Mailing Address - Country:US
Mailing Address - Phone:252-482-2127
Mailing Address - Fax:252-482-5218
Practice Address - Street 1:323 S BROAD ST
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-1933
Practice Address - Country:US
Practice Address - Phone:252-482-2127
Practice Address - Fax:252-482-5218
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLOUNT'S MUTUAL DRUGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-16
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC01464183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7336390Medicaid
NC0587770001Medicare NSC