Provider Demographics
NPI:1588795488
Name:PUNGO RIVER PHARMACY INC
Entity type:Organization
Organization Name:PUNGO RIVER PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:252-943-2585
Mailing Address - Street 1:892 US HIGHWAY 264 BYP
Mailing Address - Street 2:
Mailing Address - City:BELHAVEN
Mailing Address - State:NC
Mailing Address - Zip Code:27810-9771
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:892 US HIGHWAY 264 BYP
Practice Address - Street 2:
Practice Address - City:BELHAVEN
Practice Address - State:NC
Practice Address - Zip Code:27810-9771
Practice Address - Country:US
Practice Address - Phone:252-943-2585
Practice Address - Fax:252-943-3076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC045203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0075242Medicaid
3403780OtherOTHER ID NUMBER