Healthcare Provider Details

I. General information

NPI: 1588811863
Provider Name (Legal Business Name): BRENT JUSTIN ICENHOUR PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 08/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 N SALISBURY AVE
SPENCER NC
28159-2513
US

IV. Provider business mailing address

317 N SALISBURY AVE
SPENCER NC
28159-2513
US

V. Phone/Fax

Practice location:
  • Phone: 704-633-1604
  • Fax: 704-633-9660
Mailing address:
  • Phone: 704-633-1604
  • Fax: 704-633-9660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number19068
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: