Provider Demographics
NPI:1215276423
Name:WHITE STAR DISCOUNT PHARMACY OF TROY INC
Entity type:Organization
Organization Name:WHITE STAR DISCOUNT PHARMACY OF TROY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KARYEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:910-572-4913
Mailing Address - Street 1:436 ALBEMARLE RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NC
Mailing Address - Zip Code:27371-3102
Mailing Address - Country:US
Mailing Address - Phone:910-572-2129
Mailing Address - Fax:910-572-9606
Practice Address - Street 1:436 ALBEMARLE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NC
Practice Address - Zip Code:27371-3102
Practice Address - Country:US
Practice Address - Phone:910-572-2129
Practice Address - Fax:910-572-9606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC042373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3421170OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NC0625095Medicaid