Healthcare Provider Details

I. General information

NPI: 1881820454
Provider Name (Legal Business Name): JOHN CHRISTOPHER HIGGINBOTHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 06/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7127 HARPER ROAD
GLEN DANIEL WV
25844
US

IV. Provider business mailing address

RR 1 BOX 206R
FAYETTEVILLE WV
25840-9743
US

V. Phone/Fax

Practice location:
  • Phone: 304-934-4001
  • Fax: 304-934-4004
Mailing address:
  • Phone: 304-640-7661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP6202
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: