=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134678774
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTH INNOVATIONS OF LAURINBURG, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2016
-----------------------------------------------------
Last Update Date | 09/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 S MAIN ST
-----------------------------------------------------
City | LAURINBURG
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28352-4736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-361-4731
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 901 S MAIN ST
-----------------------------------------------------
City | LAURINBURG
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28352-4736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-361-4731
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST / OWNER
-----------------------------------------------------
Name | TIMOTHY HALL CLARK
-----------------------------------------------------
Credential | PHARMACIST
-----------------------------------------------------
Telephone | 910-361-4731
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0002X
-----------------------------------------------------
Taxonomy Name | Clinic Pharmacy
-----------------------------------------------------
License Number | 11069
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------