Provider Demographics
NPI:1306110978
Name:REALO DISCOUNT DRUG STORE OF GREENE CO INC
Entity type:Organization
Organization Name:REALO DISCOUNT DRUG STORE OF GREENE CO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:COLON
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:252-747-7004
Mailing Address - Street 1:104 PARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SNOW HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28580-1336
Mailing Address - Country:US
Mailing Address - Phone:252-747-7004
Mailing Address - Fax:252-747-1029
Practice Address - Street 1:104 PARKWOOD DR
Practice Address - Street 2:
Practice Address - City:SNOW HILL
Practice Address - State:NC
Practice Address - Zip Code:28580-1336
Practice Address - Country:US
Practice Address - Phone:252-747-7004
Practice Address - Fax:252-747-1029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10514333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1184949810Medicaid