Provider Demographics
NPI:1215979034
Name:WALKERTOWN FAMILY PHARMACY INC
Entity type:Organization
Organization Name:WALKERTOWN FAMILY PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:D
Authorized Official - Phone:336-595-6979
Mailing Address - Street 1:2905 DARROW RD
Mailing Address - Street 2:
Mailing Address - City:WALKERTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27051-9682
Mailing Address - Country:US
Mailing Address - Phone:336-595-6979
Mailing Address - Fax:336-595-7079
Practice Address - Street 1:2905 DARROW RD
Practice Address - Street 2:
Practice Address - City:WALKERTOWN
Practice Address - State:NC
Practice Address - Zip Code:27051-9682
Practice Address - Country:US
Practice Address - Phone:336-595-6979
Practice Address - Fax:336-595-7079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC092173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2065498OtherPK
NC0347307Medicaid