=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295033686
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARMAINE B ROZANOV-OVERHOLT PH.D., R.PH.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2011
-----------------------------------------------------
Last Update Date | 03/09/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3440 ROBINHOOD RD
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27106-4702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-768-6610
-----------------------------------------------------
Fax | 336-768-6201
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 259 CINNAMON WAY
-----------------------------------------------------
City | CLEMMONS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27012-7263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-764-8389
-----------------------------------------------------
Fax | 336-764-8389
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 18092
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 03326788
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------