Provider Demographics
NPI:1538200456
Name:SELF MED RX MAIN STREET PHARMACY INC
Entity type:Organization
Organization Name:SELF MED RX MAIN STREET PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:M
Authorized Official - Last Name:BENTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-342-6450
Mailing Address - Street 1:PO BOX 6827
Mailing Address - Street 2:C/O SELF MED RX INC
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315
Mailing Address - Country:US
Mailing Address - Phone:800-342-6450
Mailing Address - Fax:404-614-0322
Practice Address - Street 1:460 MAIN ST
Practice Address - Street 2:
Practice Address - City:HIGHLANDS
Practice Address - State:NC
Practice Address - Zip Code:28741
Practice Address - Country:US
Practice Address - Phone:828-526-8845
Practice Address - Fax:828-526-2367
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SELF-MED RX INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-12
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC080613336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3439646OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NC0565200Medicaid