Healthcare Provider Details

I. General information

NPI: 1407853260
Provider Name (Legal Business Name): MARK CLONINGER PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 DODD STREET
SPRING HOPE NC
27882
US

IV. Provider business mailing address

1212 NARRON FARM RD
ZEBULON NC
27597-5730
US

V. Phone/Fax

Practice location:
  • Phone: 252-478-5969
  • Fax: 252-478-2978
Mailing address:
  • Phone: 919-269-4495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10452
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: