Provider Demographics
NPI:1700556644
Name:HAISLIP, MIRANDA NEAL
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:NEAL
Last Name:HAISLIP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7384 AURELIAN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:HALIFAX
Mailing Address - State:NC
Mailing Address - Zip Code:27839-9235
Mailing Address - Country:US
Mailing Address - Phone:252-532-0551
Mailing Address - Fax:
Practice Address - Street 1:2150 US HIGHWAY 13 S
Practice Address - Street 2:
Practice Address - City:AHOSKIE
Practice Address - State:NC
Practice Address - Zip Code:27910-9481
Practice Address - Country:US
Practice Address - Phone:252-332-3545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30792183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC30792OtherPHARMACY LICENSE