Provider Demographics
NPI:1508380098
Name:HENSON, MARVIN JAMAAL JR
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:JAMAAL
Last Name:HENSON
Suffix:JR
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 1:3452 BRIARCLIFF DR APT N
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5426
Mailing Address - Country:US
Mailing Address - Phone:423-335-9199
Mailing Address - Fax:
Practice Address - Street 1:1500 MARTIN LUTHER KING JR PKWY SE
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-6524
Practice Address - Country:US
Practice Address - Phone:252-373-3185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27232183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist