Provider Demographics
NPI:1841624301
Name:VALENTINE, JAN SUSAN
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:SUSAN
Last Name:VALENTINE
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 1:1909 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-4309
Mailing Address - Country:US
Mailing Address - Phone:704-873-3553
Mailing Address - Fax:
Practice Address - Street 1:1909 E BROAD ST
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-4309
Practice Address - Country:US
Practice Address - Phone:704-873-3553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-02
Last Update Date:2013-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15708183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist