1720150782 NPI number — ARCHIE WILLIS GAINES JR. R.PH.

Table of content: TAYLOR AGBULOS (NPI 1407555378)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720150782 NPI number — ARCHIE WILLIS GAINES JR. R.PH.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAINES
Provider First Name:
ARCHIE
Provider Middle Name:
WILLIS
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
R.PH.
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:
1720150782
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:
PO BOX 1940
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEAVERVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28787-1940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-275-2232
Provider Business Mailing Address Fax Number:
828-645-8245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
690 HAYWOOD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28806-3260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-275-2232
Provider Business Practice Location Address Fax Number:
828-645-8245
Provider Enumeration Date:
11/14/2006

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:  7191 , 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)





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