Provider Demographics
NPI:1053372342
Name:PERSON STREET PHARMACY OF RALEIGH, INC.
Entity type:Organization
Organization Name:PERSON STREET PHARMACY OF RALEIGH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:FORREST
Authorized Official - Middle Name:MIKE
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:919-832-6432
Mailing Address - Street 1:702 N PERSON ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-1216
Mailing Address - Country:US
Mailing Address - Phone:919-832-6432
Mailing Address - Fax:919-833-7581
Practice Address - Street 1:702 N PERSON ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-1216
Practice Address - Country:US
Practice Address - Phone:919-832-6432
Practice Address - Fax:919-833-7581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC03305333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0925149Medicaid
NC0925149Medicaid