Provider Demographics
NPI:1831491083
Name:PRIDGEN, CHARLA SMITH (RPH)
Entity Type:Individual
Prefix:
First Name:CHARLA
Middle Name:SMITH
Last Name:PRIDGEN
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 1:8127 RIVERWAY RD
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27023-9509
Mailing Address - Country:US
Mailing Address - Phone:336-945-4424
Mailing Address - Fax:
Practice Address - Street 1:1209 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2301
Practice Address - Country:US
Practice Address - Phone:336-526-0011
Practice Address - Fax:336-526-6005
Is Sole Proprietor?:No
Enumeration Date:2010-11-20
Last Update Date:2010-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC07487183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist