Provider Demographics
NPI:1891943544
Name:HENSON, CALLISTA M (RPH)
Entity Type:Individual
Prefix:
First Name:CALLISTA
Middle Name:M
Last Name:HENSON
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:PO BOX 36839
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28236-6839
Mailing Address - Country:US
Mailing Address - Phone:704-576-4162
Mailing Address - Fax:704-364-4574
Practice Address - Street 1:2516 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-5313
Practice Address - Country:US
Practice Address - Phone:704-344-6494
Practice Address - Fax:704-344-6469
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-07
Last Update Date:2008-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI25452183500000X
NC16299183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist