Healthcare Provider Details

I. General information

NPI: 1679131775
Provider Name (Legal Business Name): VAXCLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2019
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 WINCHESTER RD STE 13
LEXINGTON KY
40505-4132
US

IV. Provider business mailing address

1521 TAMWORTH DR
CHARLOTTE NC
28210-4109
US

V. Phone/Fax

Practice location:
  • Phone: 606-424-2781
  • Fax:
Mailing address:
  • Phone: 606-424-2781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. SAMANTHA HOWARD
Title or Position: PHARMACIST
Credential: PHARMD
Phone: 606-424-2781