Provider Demographics
NPI:1821575424
Name:GUPTA, AJAY
Entity Type:Individual
Prefix:
First Name:AJAY
Middle Name:
Last Name:GUPTA
Suffix:
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 1:2015 GUM BRANCH RD APT 1215
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-4586
Mailing Address - Country:US
Mailing Address - Phone:352-682-1294
Mailing Address - Fax:
Practice Address - Street 1:2001 NEUSE BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28560-3470
Practice Address - Country:US
Practice Address - Phone:252-672-8365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27646183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist