Provider Demographics
NPI:1871899617
Name:ANDERSON CREEK PHARMACY INC
Entity type:Organization
Organization Name:ANDERSON CREEK PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIPPS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:910-497-6337
Mailing Address - Street 1:PO BOX 470
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28356-0470
Mailing Address - Country:US
Mailing Address - Phone:910-497-6337
Mailing Address - Fax:
Practice Address - Street 1:6779 OVERHILLS RD
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:NC
Practice Address - Zip Code:28390-8873
Practice Address - Country:US
Practice Address - Phone:910-497-6337
Practice Address - Fax:910-497-0590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-26
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC109283336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0435545Medicaid
2128603OtherPK
NC0435545Medicaid
6511120001Medicare NSC