Provider Demographics
NPI:1053947366
Name:EDEN DRUG, INC.
Entity type:Organization
Organization Name:EDEN DRUG, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:CROUCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-627-4854
Mailing Address - Street 1:103 W STADIUM DR
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-3329
Mailing Address - Country:US
Mailing Address - Phone:336-627-4854
Mailing Address - Fax:
Practice Address - Street 1:103 W STADIUM DR
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-3329
Practice Address - Country:US
Practice Address - Phone:336-627-4854
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-18
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0795443Medicaid