1407853260 NPI number — MARK CLONINGER PHARMACIST

Table of content: MARK CLONINGER PHARMACIST (NPI 1407853260)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407853260 NPI number — MARK CLONINGER PHARMACIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLONINGER
Provider First Name:
MARK
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMACIST
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:
1407853260
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1212 NARRON FARM RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ZEBULON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27597-5730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-269-4495
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
98 DODD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRING HOPE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27882
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-478-5969
Provider Business Practice Location Address Fax Number:
252-478-2978
Provider Enumeration Date:
07/07/2005

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:  10452 , 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: 0645440 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com