Provider Demographics
NPI:1578661500
Name:THE OLD NORTH STATE DRUG CO
Entity type:Organization
Organization Name:THE OLD NORTH STATE DRUG CO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDSON MOTLOW
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:336-248-5623
Mailing Address - Street 1:405 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27292-4109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:405 E CENTER ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292-4109
Practice Address - Country:US
Practice Address - Phone:336-248-5623
Practice Address - Fax:336-248-6722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC055273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3408300OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NC295527Medicaid
NC7701779Medicaid