Provider Demographics
NPI:1376091330
Name:BILLINGSLEY, JOHN SAMUEL IV
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:SAMUEL
Last Name:BILLINGSLEY
Suffix:IV
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 1:1545 LEE PEARSON RD
Mailing Address - Street 2:
Mailing Address - City:GRANITE FALLS
Mailing Address - State:NC
Mailing Address - Zip Code:28630-9254
Mailing Address - Country:US
Mailing Address - Phone:804-836-9370
Mailing Address - Fax:
Practice Address - Street 1:2700 S NC 127 HWY
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-9130
Practice Address - Country:US
Practice Address - Phone:828-294-0058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26493183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist