Provider Demographics
NPI:1083225742
Name:CHILDRESS, AUSTIN ALEXANDER
Entity Type:Individual
Prefix:DR
First Name:AUSTIN
Middle Name:ALEXANDER
Last Name:CHILDRESS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3634 REYNOLDA RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-2230
Mailing Address - Country:US
Mailing Address - Phone:336-923-2367
Mailing Address - Fax:336-923-2807
Practice Address - Street 1:3634 REYNOLDA RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-2230
Practice Address - Country:US
Practice Address - Phone:336-923-2367
Practice Address - Fax:336-923-2807
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29486183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist