Provider Demographics
NPI:1831483080
Name:KEPHART, MARK ALAN
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:KEPHART
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 1:5001 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-4513
Mailing Address - Country:US
Mailing Address - Phone:336-659-0391
Mailing Address - Fax:336-760-2834
Practice Address - Street 1:5001 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-4513
Practice Address - Country:US
Practice Address - Phone:336-659-0391
Practice Address - Fax:336-760-2834
Is Sole Proprietor?:No
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7559183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist