Healthcare Provider Details

I. General information

NPI: 1881244309
Provider Name (Legal Business Name): JESSICA WINE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2019
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 N BRIGHTLEAF BLVD
SMITHFIELD NC
27577-4674
US

IV. Provider business mailing address

3701 ASHBROOK DR NW APT 301
WILSON NC
27896-7624
US

V. Phone/Fax

Practice location:
  • Phone: 919-989-4058
  • Fax:
Mailing address:
  • Phone: 910-736-6895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28470
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: