Provider Demographics
NPI:1275814592
Name:DOHERTY, ANDREW J III
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:J
Last Name:DOHERTY
Suffix:III
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 1:117A VILLAGE RD NE
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-7413
Mailing Address - Country:US
Mailing Address - Phone:910-371-2532
Mailing Address - Fax:910-371-1614
Practice Address - Street 1:117A VILLAGE RD NE
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-7413
Practice Address - Country:US
Practice Address - Phone:910-371-2532
Practice Address - Fax:910-371-1614
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21290183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist