Healthcare Provider Details

I. General information

NPI: 1154616308
Provider Name (Legal Business Name): JACQUELINE SUSANNE HURLBUT RPH.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2011
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3633 CLEMMONS RD
CLEMMONS NC
27012-8725
US

IV. Provider business mailing address

3633 CLEMMONS RD
CLEMMONS NC
27012-8725
US

V. Phone/Fax

Practice location:
  • Phone: 335-293-1395
  • Fax: 336-293-1394
Mailing address:
  • Phone: 336-293-1395
  • Fax: 336-293-1394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number13059
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: