Healthcare Provider Details

I. General information

NPI: 1912553561
Provider Name (Legal Business Name): JUSTIN EZENNUBIA PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2019
Last Update Date: 08/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13845 CONLAN CIR
CHARLOTTE NC
28277-2705
US

IV. Provider business mailing address

6625 COW HOLLOW DR APT 2224
CHARLOTTE NC
28226-8583
US

V. Phone/Fax

Practice location:
  • Phone: 704-544-2092
  • Fax:
Mailing address:
  • Phone: 704-771-2436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number42161
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28998
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: