Provider Demographics
NPI:1184839417
Name:JENNINGS, WILLIE H (RPH, FASCP)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:H
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:RPH, FASCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4364 SARTIN RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27217-7522
Mailing Address - Country:US
Mailing Address - Phone:336-228-3445
Mailing Address - Fax:
Practice Address - Street 1:138 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-5847
Practice Address - Country:US
Practice Address - Phone:336-226-1663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC44491835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric