Healthcare Provider Details

I. General information

NPI: 1083928675
Provider Name (Legal Business Name): ANDREW FORMAN THORNDYKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2010
Last Update Date: 08/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

852 SUNSET BLVD N
SUNSET BEACH NC
28468-4262
US

IV. Provider business mailing address

853 N SANDPIPER CLUB DR SW
SUNSET BEACH NC
28468-5807
US

V. Phone/Fax

Practice location:
  • Phone: 910-579-4503
  • Fax:
Mailing address:
  • Phone: 910-575-4925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number05967
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: