Provider Demographics
NPI:1720340268
Name:HINES, KATINNA EVETTE (RPH)
Entity Type:Individual
Prefix:
First Name:KATINNA
Middle Name:EVETTE
Last Name:HINES
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 1:1245 CONCORD PKWY N
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-4325
Mailing Address - Country:US
Mailing Address - Phone:704-795-9868
Mailing Address - Fax:704-788-3805
Practice Address - Street 1:1245 CONCORD PKWY N
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-4325
Practice Address - Country:US
Practice Address - Phone:704-795-9868
Practice Address - Fax:704-788-3805
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH019859183500000X
FLPS31866183500000X
NC17489183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
3432729OtherNABP
NC0135723Medicaid
56-1390087OtherFEDERAL TAX ID
56-1390087OtherFEDERAL TAX ID