1215216411 NPI number — DR. DUSTIN MATHEW ALLEN PHARMD

Table of content: DR. DUSTIN MATHEW ALLEN PHARMD (NPI 1215216411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215216411 NPI number — DR. DUSTIN MATHEW ALLEN PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALLEN
Provider First Name:
DUSTIN
Provider Middle Name:
MATHEW
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215216411
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1039 LOWES LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRON STATION
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28080-9647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-310-8059
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4428 TAGGART CREEK RD STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28208-5400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-943-9639
Provider Business Practice Location Address Fax Number:
704-536-9812
Provider Enumeration Date:
08/05/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  21705 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)