Provider Demographics
NPI:1386659985
Name:KAITLYNS PHARMACY INC
Entity type:Organization
Organization Name:KAITLYNS PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:VU
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:704-588-9623
Mailing Address - Street 1:9100 S TRYON ST STE A
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-3113
Mailing Address - Country:US
Mailing Address - Phone:704-588-9623
Mailing Address - Fax:704-588-9624
Practice Address - Street 1:9100 S TRYON ST STE A
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-3113
Practice Address - Country:US
Practice Address - Phone:704-588-9623
Practice Address - Fax:704-588-9624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC092263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2065729OtherPK
NC0426412Medicaid
NC7704459Medicaid
5641580001Medicare NSC