Provider Demographics
NPI:1881820454
Name:HIGGINBOTHAM, JOHN CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHRISTOPHER
Last Name:HIGGINBOTHAM
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:RR 1 BOX 206R
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-9743
Mailing Address - Country:US
Mailing Address - Phone:304-640-7661
Mailing Address - Fax:
Practice Address - Street 1:7127 HARPER ROAD
Practice Address - Street 2:
Practice Address - City:GLEN DANIEL
Practice Address - State:WV
Practice Address - Zip Code:25844
Practice Address - Country:US
Practice Address - Phone:304-934-4001
Practice Address - Fax:304-934-4004
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP6202183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist