Provider Demographics
NPI:1558656363
Name:FOUNTAIN, ROBERT LEE JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LEE
Last Name:FOUNTAIN
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 N MARTIN LUTHER KING JR DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-4331
Mailing Address - Country:US
Mailing Address - Phone:336-725-5917
Mailing Address - Fax:336-725-2844
Practice Address - Street 1:540 N MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-4331
Practice Address - Country:US
Practice Address - Phone:336-725-5917
Practice Address - Fax:336-725-2844
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5697183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5697OtherNC PHARMACY LICENSE