Provider Demographics
NPI:1841598745
Name:SMITH, IVAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:
Last Name:SMITH
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 1:4059 NC HWY 105
Mailing Address - Street 2:RITE AID PHARMACY
Mailing Address - City:SUGAR MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28604
Mailing Address - Country:US
Mailing Address - Phone:828-898-8971
Mailing Address - Fax:
Practice Address - Street 1:4059 NC HWY 105
Practice Address - Street 2:RITE AID PHARMACY
Practice Address - City:SUGAR MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28604
Practice Address - Country:US
Practice Address - Phone:828-898-8971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21444183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist