1588647648 NPI number — MARTHA FENN NANCE RPH

Table of content: MARTHA FENN NANCE RPH (NPI 1588647648)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588647648 NPI number — MARTHA FENN NANCE RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NANCE
Provider First Name:
MARTHA
Provider Middle Name:
FENN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RPH
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:
1588647648
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:
309 FAIRIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JAMESTOWN
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27282-9472
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-454-2360
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
GOVE SHC PHARMACY UNCG
Provider Second Line Business Practice Location Address:
GRAY DRIVE
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27402-6170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-334-3348
Provider Business Practice Location Address Fax Number:
336-334-5343
Provider Enumeration Date:
11/22/2005

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:  5715 , 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: 5715 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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