Provider Demographics
NPI:1497292023
Name:SIMON, TUKEISHA
Entity Type:Individual
Prefix:
First Name:TUKEISHA
Middle Name:
Last Name:SIMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 LILLINGTON HWY
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:NC
Mailing Address - Zip Code:28390-2119
Mailing Address - Country:US
Mailing Address - Phone:910-436-3103
Mailing Address - Fax:910-436-2599
Practice Address - Street 1:670 LILLINGTON HWY
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:NC
Practice Address - Zip Code:28390-2119
Practice Address - Country:US
Practice Address - Phone:910-436-3103
Practice Address - Fax:910-436-2599
Is Sole Proprietor?:No
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19082183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist