Healthcare Provider Details

I. General information

NPI: 1679495311
Provider Name (Legal Business Name): MARSHALL KEITH PATE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 N BREAZEALE AVE
MOUNT OLIVE NC
28365-1120
US

IV. Provider business mailing address

1103 N BREAZEALE AVE
MOUNT OLIVE NC
28365-1120
US

V. Phone/Fax

Practice location:
  • Phone: 919-658-8510
  • Fax:
Mailing address:
  • Phone: 919-658-8510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number34780
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: