Organization
BEAM AND BLIZZARD, LLC
Active
Other names
Indian Trail Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
TERRY A DEVINE JR. PHARMD (PHARMACY MANAGER)
(704) 821-7617
Entity
Organization
Contact information
Practice address
106 INDIAN TRAIL RD S, INDIAN TRAIL, NC 28079-9669
(704) 821-7617
(704) 821-0177
Mailing address
106 INDIAN TRAIL RD S, INDIAN TRAIL, NC 28079-9669
(704) 821-7617
(704) 821-0177
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
Primary
11558
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0905117
—
NC
01
—
6973150001
MEDICARE PTAN
NC
Enumeration date
11/14/2014
Last updated
12/01/2014
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