Provider Demographics
NPI:1790876647
Name:LONDON, DOUGLAS (RPH)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:
Last Name:LONDON
Suffix:
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 1:6527 BREVARD RD.
Mailing Address - Street 2:P.O. BOX 351
Mailing Address - City:ETOWAH
Mailing Address - State:NC
Mailing Address - Zip Code:28729-0351
Mailing Address - Country:US
Mailing Address - Phone:828-890-0022
Mailing Address - Fax:828-890-0028
Practice Address - Street 1:6527 BREVARD RD.
Practice Address - Street 2:
Practice Address - City:ETOWAH
Practice Address - State:NC
Practice Address - Zip Code:28729-0351
Practice Address - Country:US
Practice Address - Phone:828-890-0022
Practice Address - Fax:828-890-0028
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14088183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0445626Medicaid
NC3876750001Medicare ID - Type Unspecified