Provider Demographics
NPI:1740570670
Name:CLEVENGER, ROBERT BRENT III
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:BRENT
Last Name:CLEVENGER
Suffix:III
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 1:1533 SOUTH BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-4723
Mailing Address - Country:US
Mailing Address - Phone:704-342-4558
Mailing Address - Fax:704-377-6246
Practice Address - Street 1:1533 SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4723
Practice Address - Country:US
Practice Address - Phone:704-342-4558
Practice Address - Fax:704-377-6246
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-12
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8076183500000X
MS9503183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist