Provider Demographics
NPI:1194874123
Name:MEDICAL VILLAGE APOTHECARY INC
Entity type:Organization
Organization Name:MEDICAL VILLAGE APOTHECARY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:GARDNER
Authorized Official - Last Name:SKEEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:336-228-1336
Mailing Address - Street 1:1610 VAUGHN RD STE K
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27217-2919
Mailing Address - Country:US
Mailing Address - Phone:336-228-1336
Mailing Address - Fax:336-227-0764
Practice Address - Street 1:1610 VAUGHN RD STE K
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217-2919
Practice Address - Country:US
Practice Address - Phone:336-228-1336
Practice Address - Fax:336-227-0764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC02144333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1194874123Medicaid
3404237OtherOTHER ID NUMBER
NC0015107Medicaid
NC7701522Medicaid