Provider Demographics
NPI:1710296678
Name:ATWATER, SIREATTA GIBSON (RPH)
Entity Type:Individual
Prefix:
First Name:SIREATTA
Middle Name:GIBSON
Last Name:ATWATER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3737 N. ROXBORO RD.
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705
Mailing Address - Country:US
Mailing Address - Phone:919-471-4166
Mailing Address - Fax:919-620-7926
Practice Address - Street 1:3737 N. ROXBORO RD.
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705
Practice Address - Country:US
Practice Address - Phone:919-471-4166
Practice Address - Fax:919-620-7926
Is Sole Proprietor?:No
Enumeration Date:2010-09-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11339183500000X
VA0202205196183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist