Healthcare Provider Details

I. General information

NPI: 1114378312
Provider Name (Legal Business Name): PREMISE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7855 DORAL DR
TOBACCOVILLE NC
27050-9002
US

IV. Provider business mailing address

475 SUMMIT SQUARE BLVD
WINSTON SALEM NC
27105-1485
US

V. Phone/Fax

Practice location:
  • Phone: 336-741-1319
  • Fax: 336-714-1803
Mailing address:
  • Phone: 336-377-3979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number12514
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number StateNULL

VIII. Authorized Official

Name: JOYCE JENSEN
Title or Position: DIRECTOR SITE OPERATIONS
Credential:
Phone: 904-401-1175