Provider Demographics
NPI:1871560631
Name:DAMERON DRUG STORE INC
Entity type:Organization
Organization Name:DAMERON DRUG STORE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:DAMERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-653-3089
Mailing Address - Street 1:100 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TABOR CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28463-1910
Mailing Address - Country:US
Mailing Address - Phone:910-653-3089
Mailing Address - Fax:910-653-5839
Practice Address - Street 1:100 S MAIN ST
Practice Address - Street 2:
Practice Address - City:TABOR CITY
Practice Address - State:NC
Practice Address - Zip Code:28463
Practice Address - Country:US
Practice Address - Phone:910-653-3089
Practice Address - Fax:910-653-5839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-01
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NC009173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0245100Medicaid
SC7N0917Medicaid
2067496OtherPK
NC0245100Medicaid