Healthcare Provider Details

I. General information

NPI: 1295025450
Provider Name (Legal Business Name): MATHEW KERSHAW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2011
Last Update Date: 04/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1691 WESTCHESTER DR
HIGH POINT NC
27262
US

IV. Provider business mailing address

207 KIAWAH ISLAND DR
WINSTON SALEM NC
27107
US

V. Phone/Fax

Practice location:
  • Phone: 336-887-7474
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number16319
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: