Healthcare Provider Details

I. General information

NPI: 1265707228
Provider Name (Legal Business Name): FAYETTEVILLE FAMILY MEDICAL CARE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2012
Last Update Date: 03/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1307 AVON ST
FAYETTEVILLE NC
28304-4423
US

IV. Provider business mailing address

1307 AVON ST
FAYETTEVILLE NC
28304-4423
US

V. Phone/Fax

Practice location:
  • Phone: 910-323-1718
  • Fax: 910-323-3834
Mailing address:
  • Phone: 910-323-1718
  • Fax: 910-323-3834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number07787
License Number StateNC

VIII. Authorized Official

Name: MRS. ALICE M KUGLER
Title or Position: ADMINISTRATOR
Credential:
Phone: 910-323-1718