1548378300 NPI number — A&B WYATT ENTERPRISES, INC.

Table of content: DR. MICHAEL ANDREW SULLIVAN M.D. (NPI 1689654899)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548378300 NPI number — A&B WYATT ENTERPRISES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
A&B WYATT ENTERPRISES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1548378300
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 258
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STONEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27048-0258
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-573-2200
Provider Business Mailing Address Fax Number:
336-573-2201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 N HENRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STONEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-573-2200
Provider Business Practice Location Address Fax Number:
336-573-2201
Provider Enumeration Date:
08/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WYATT
Authorized Official First Name:
BRYAN
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
OWNER/PHARMACIST MANAGER
Authorized Official Telephone Number:
336-573-2200

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  08149 , 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: 0795775 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7704002 . This is a "MEDICAID DME SUPPLIER NUM" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 3440601 . This is a "NCPDP NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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