Provider Demographics
NPI:1316180193
Name:GO PHARMACY INC
Entity type:Organization
Organization Name:GO PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRENTON
Authorized Official - Middle Name:
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-398-5467
Mailing Address - Street 1:PO BOX 479
Mailing Address - Street 2:
Mailing Address - City:LAKE WACCAMAW
Mailing Address - State:NC
Mailing Address - Zip Code:28450-0479
Mailing Address - Country:US
Mailing Address - Phone:910-646-3112
Mailing Address - Fax:910-646-1126
Practice Address - Street 1:1911 S 17TH ST STE 100
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6663
Practice Address - Country:US
Practice Address - Phone:910-646-3112
Practice Address - Fax:910-646-1126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-09
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336M0002X, 332B00000X, 333600000X
NC112033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0245902Medicaid
2133087OtherPK