=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447796115
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEREMY LIPSCOMB PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2017
-----------------------------------------------------
Last Update Date | 01/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1550 SKIBO RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28303-3478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-868-5242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114 APPOMATTOX DR
-----------------------------------------------------
City | CAMERON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28326-5536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-559-9845
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 26033
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------