Healthcare Provider Details

I. General information

NPI: 1083085526
Provider Name (Legal Business Name): NICOLE LOCKLEAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2015
Last Update Date: 10/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 HIGHWAY 711 EAST
PEMBROKE NC
28372
US

IV. Provider business mailing address

930 HIGHWAY 711 EAST
PEMBROKE NC
28372
US

V. Phone/Fax

Practice location:
  • Phone: 910-522-5250
  • Fax: 910-522-1305
Mailing address:
  • Phone: 910-522-5250
  • Fax: 910-522-1305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number12634
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: