1790060929 NPI number — DR. BROCK ELLIOT WILEY PHARM.D

Table of content: DR. BROCK ELLIOT WILEY PHARM.D (NPI 1790060929)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790060929 NPI number — DR. BROCK ELLIOT WILEY PHARM.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILEY
Provider First Name:
BROCK
Provider Middle Name:
ELLIOT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARM.D
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:
1790060929
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 235
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENLY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27542-0235
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-284-2010
Provider Business Mailing Address Fax Number:
919-284-2231

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 W 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENLY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27542-5004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-284-2010
Provider Business Practice Location Address Fax Number:
919-284-2231
Provider Enumeration Date:
10/19/2011

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:  19919 , 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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