Healthcare Provider Details

I. General information

NPI: 1790060929
Provider Name (Legal Business Name): BROCK ELLIOT WILEY PHARM.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 11/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 W 2ND ST
KENLY NC
27542-5004
US

IV. Provider business mailing address

PO BOX 235
KENLY NC
27542-0235
US

V. Phone/Fax

Practice location:
  • Phone: 919-284-2010
  • Fax: 919-284-2231
Mailing address:
  • Phone: 919-284-2010
  • Fax: 919-284-2231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number19919
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: