Healthcare Provider Details

I. General information

NPI: 1376983478
Provider Name (Legal Business Name): COURTNEY T HUMPHRIES PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COURTNEY F TATE PHARMD

II. Dates (important events)

Enumeration Date: 07/03/2013
Last Update Date: 07/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 CRESTDALE RD
MATTHEWS NC
28105-1700
US

IV. Provider business mailing address

813 CEDAR ST
MC ADENVILLE NC
28101-9001
US

V. Phone/Fax

Practice location:
  • Phone: 704-844-4780
  • Fax: 704-844-4208
Mailing address:
  • Phone: 704-472-7999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number35434
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number23214
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: