1164542452 NPI number — JOHN DAVIE WAGGETT RPH

Table of content: CHARLES JACKSON BREEDLOVE PTA (NPI 1427620814)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164542452 NPI number — JOHN DAVIE WAGGETT RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGGETT
Provider First Name:
JOHN
Provider Middle Name:
DAVIE
Provider Name Prefix Text:
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:
1164542452
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
612 BAYSHORE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28411-9419
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-686-1661
Provider Business Mailing Address Fax Number:
910-686-1675

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2059 CAROLINA BEACH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28401-7239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-762-6278
Provider Business Practice Location Address Fax Number:
910-343-0710
Provider Enumeration Date:
03/30/2007

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:  7169 , 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: 7169 . This is a "BOARD OF PHARMACY" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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