1255732715 NPI number — DR. ERICA NICOLE MASTER PHARMD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255732715 NPI number — DR. ERICA NICOLE MASTER PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MASTER
Provider First Name:
ERICA
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
F

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:
1255732715
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1701 4TH AVE
Provider Second Line Business Mailing Address:
KMART PHARMACY #4188
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25387-2415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-346-0829
Provider Business Mailing Address Fax Number:
304-344-0563

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 4TH AVE
Provider Second Line Business Practice Location Address:
KMART PHARMACY #4188
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25387-2415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-346-0829
Provider Business Practice Location Address Fax Number:
304-344-0563
Provider Enumeration Date:
09/15/2014

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:  RP0007104 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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