Provider Demographics
NPI:1396043063
Name:BLACK, TAMMY KINNEY (RPH)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:KINNEY
Last Name:BLACK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3440 ROBINHOOD RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-4702
Mailing Address - Country:US
Mailing Address - Phone:336-768-6610
Mailing Address - Fax:336-768-6201
Practice Address - Street 1:3440 ROBINHOOD RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-4702
Practice Address - Country:US
Practice Address - Phone:336-768-6610
Practice Address - Fax:336-768-6201
Is Sole Proprietor?:No
Enumeration Date:2011-03-04
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC09054183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist