Provider Demographics
NPI:1770888752
Name:BLACK, EARL CLIFFORD III (RPH)
Entity type:Individual
Prefix:MR
First Name:EARL
Middle Name:CLIFFORD
Last Name:BLACK
Suffix:III
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4376 SCENIC VIEW CT
Mailing Address - Street 2:
Mailing Address - City:IRON STATION
Mailing Address - State:NC
Mailing Address - Zip Code:28080-8424
Mailing Address - Country:US
Mailing Address - Phone:704-307-7100
Mailing Address - Fax:
Practice Address - Street 1:1403 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-3901
Practice Address - Country:US
Practice Address - Phone:704-735-5159
Practice Address - Fax:704-748-1257
Is Sole Proprietor?:No
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC006766183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0555110Medicaid