Provider Demographics
NPI:1497220248
Name:ECCLESTONE, MARK BRIAN JR (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:BRIAN
Last Name:ECCLESTONE
Suffix:JR
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 MOUNT ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:ARDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28704-2831
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:505 SMOKEY PARK HWY
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28806-1030
Practice Address - Country:US
Practice Address - Phone:828-667-5457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27750183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC27750OtherNORTH CAROLINA BOARD OF PHARMACY