1790876647 NPI number — MR. DOUGLAS LONDON RPH

Table of content: MR. DOUGLAS LONDON RPH (NPI 1790876647)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790876647 NPI number — MR. DOUGLAS LONDON RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LONDON
Provider First Name:
DOUGLAS
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
RPH
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:
1790876647
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6527 BREVARD RD.
Provider Second Line Business Mailing Address:
P.O. BOX 351
Provider Business Mailing Address City Name:
ETOWAH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28729-0351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-890-0022
Provider Business Mailing Address Fax Number:
828-890-0028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6527 BREVARD RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ETOWAH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28729-0351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-890-0022
Provider Business Practice Location Address Fax Number:
828-890-0028
Provider Enumeration Date:
09/27/2006

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:  14088 , 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)

  • Identifier: 0445626 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".