Provider Demographics
NPI:1194941286
Name:CALABASH FAMILY PHARMACY INC
Entity type:Organization
Organization Name:CALABASH FAMILY PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHRM MANG
Authorized Official - Prefix:
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:
Authorized Official - Last Name:TYNDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-842-4401
Mailing Address - Street 1:10080 BEACH DR SW
Mailing Address - Street 2:
Mailing Address - City:CALABASH
Mailing Address - State:NC
Mailing Address - Zip Code:28467-2712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10080 BEACH DRIVE SW
Practice Address - Street 2:
Practice Address - City:CALABASH
Practice Address - State:NC
Practice Address - Zip Code:28467
Practice Address - Country:US
Practice Address - Phone:910-579-1177
Practice Address - Fax:910-579-1877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC095093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0105497Medicaid
3408108OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NC0105497Medicaid