Provider Demographics
NPI:1588811863
Name:ICENHOUR, BRENT JUSTIN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:JUSTIN
Last Name:ICENHOUR
Suffix:
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 1:317 N SALISBURY AVE
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:NC
Mailing Address - Zip Code:28159-2513
Mailing Address - Country:US
Mailing Address - Phone:704-633-1604
Mailing Address - Fax:704-633-9660
Practice Address - Street 1:317 N SALISBURY AVE
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:NC
Practice Address - Zip Code:28159-2513
Practice Address - Country:US
Practice Address - Phone:704-633-1604
Practice Address - Fax:704-633-9660
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19068183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist