Healthcare Provider Details

I. General information

NPI: 1396800710
Provider Name (Legal Business Name): LAX COTSWOLD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4390 COLWICK RD
CHARLOTTE NC
28211-2310
US

IV. Provider business mailing address

4390 COLWICK RD
CHARLOTTE NC
28211-2310
US

V. Phone/Fax

Practice location:
  • Phone: 704-364-3444
  • Fax: 704-364-1320
Mailing address:
  • Phone: 704-364-3444
  • Fax: 704-364-1320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number12986
License Number StateNC

VIII. Authorized Official

Name: VIPUL PATEL
Title or Position: OWNER
Credential:
Phone: 704-364-3444