Healthcare Provider Details

I. General information

NPI: 1508783937
Provider Name (Legal Business Name): ALICIA INSORN BACCAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 CRESTDALE RD
MATTHEWS NC
28105-1744
US

IV. Provider business mailing address

9 PARK VILLAGE CT
GREENSBORO NC
27455-2476
US

V. Phone/Fax

Practice location:
  • Phone: 704-844-3100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number25574
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number34576
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: