Healthcare Provider Details

I. General information

NPI: 1811296064
Provider Name (Legal Business Name): EARLE WATTS ALLEN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2011
Last Update Date: 03/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 PARK ST
BELMONT NC
28012-2777
US

IV. Provider business mailing address

625 PARK ST
BELMONT NC
28012-2777
US

V. Phone/Fax

Practice location:
  • Phone: 704-825-3358
  • Fax:
Mailing address:
  • Phone: 704-825-3358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number06651
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: