Provider Demographics
NPI:1104961739
Name:CROSSROADS PHARMACY
Entity type:Organization
Organization Name:CROSSROADS PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:704-276-1078
Mailing Address - Street 1:3123 PLATEAU RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NC
Mailing Address - Zip Code:28658-8900
Mailing Address - Country:US
Mailing Address - Phone:704-276-1078
Mailing Address - Fax:704-276-1079
Practice Address - Street 1:3123 PLATEAU RD
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NC
Practice Address - Zip Code:28658-8900
Practice Address - Country:US
Practice Address - Phone:704-276-1078
Practice Address - Fax:704-276-1079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC081743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2069498OtherPK
NC0186215Medicaid
NC0186215Medicaid