Provider Demographics
NPI:1033405733
Name:AVERITT, PHILLIP LOUIS (RPH)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:LOUIS
Last Name:AVERITT
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 SPRING GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-2334
Mailing Address - Country:US
Mailing Address - Phone:336-379-1649
Mailing Address - Fax:
Practice Address - Street 1:1615 SPRING GARDEN ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-2334
Practice Address - Country:US
Practice Address - Phone:336-379-1649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10427183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist