Provider Demographics
NPI:1942582564
Name:CHESNUTT, CHARLES NICHOLAS JR
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:NICHOLAS
Last Name:CHESNUTT
Suffix:JR
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 1:9005 RICHLANDS HWY
Mailing Address - Street 2:
Mailing Address - City:RICHLANDS
Mailing Address - State:NC
Mailing Address - Zip Code:28574-6380
Mailing Address - Country:US
Mailing Address - Phone:910-324-1656
Mailing Address - Fax:910-324-2253
Practice Address - Street 1:9005 RICHLANDS HWY
Practice Address - Street 2:
Practice Address - City:RICHLANDS
Practice Address - State:NC
Practice Address - Zip Code:28574-6380
Practice Address - Country:US
Practice Address - Phone:910-324-1656
Practice Address - Fax:910-324-2253
Is Sole Proprietor?:No
Enumeration Date:2011-09-10
Last Update Date:2012-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC09379183500000X
SC14004183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist