Healthcare Provider Details

I. General information

NPI: 1114234903
Provider Name (Legal Business Name): NORTH CAROLINA A T STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2010
Last Update Date: 05/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112. N. BENBOW ROAD
GREENSBORO NC
27411-0001
US

IV. Provider business mailing address

112. N. BENBOW ROAD
GREENSBORO NC
27411-0001
US

V. Phone/Fax

Practice location:
  • Phone: 336-285-2908
  • Fax: 336-256-2903
Mailing address:
  • Phone: 336-285-2908
  • Fax: 336-256-2903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number04312
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MRS. BANNIE H HATCH
Title or Position: PHARMACY MANAGER
Credential: RPH
Phone: 336-285-2908