Provider Demographics
NPI:1306873781
Name:WESTERN WAKE MEDICAL CENTER PHARMACY
Entity type:Organization
Organization Name:WESTERN WAKE MEDICAL CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VP AND CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEVAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:919-350-8000
Mailing Address - Street 1:1900 KILDAIRE FARM RD
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-6616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 KILDAIRE FARM RD
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-6616
Practice Address - Country:US
Practice Address - Phone:919-350-2300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAKEMED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-28
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC05371333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0349WOtherBCBS