=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497108625
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN GADDY PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2016
-----------------------------------------------------
Last Update Date | 07/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 112 S SHARON AMITY RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28211-2802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-366-5684
-----------------------------------------------------
Fax | 704-366-1598
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 S SHARON AMITY RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28211-2802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-366-5684
-----------------------------------------------------
Fax | 704-366-1598
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 15937
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 12325
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------