Healthcare Provider Details

I. General information

NPI: 1164720264
Provider Name (Legal Business Name): CHRISTOPHER GRAY HOLLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2011
Last Update Date: 03/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12216 N NC HIGHWAY 150
WINSTON SALEM NC
27127-9730
US

IV. Provider business mailing address

12216 N NC HIGHWAY 150
WINSTON SALEM NC
27127-9730
US

V. Phone/Fax

Practice location:
  • Phone: 336-764-2211
  • Fax: 336-764-3714
Mailing address:
  • Phone: 336-764-2211
  • Fax: 336-764-3714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number15441
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: