Provider Demographics
NPI:1154616308
Name:HURLBUT, JACQUELINE SUSANNE (RPH)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:SUSANNE
Last Name:HURLBUT
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 1:3633 CLEMMONS RD
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8725
Mailing Address - Country:US
Mailing Address - Phone:336-293-1395
Mailing Address - Fax:336-293-1394
Practice Address - Street 1:3633 CLEMMONS RD
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8725
Practice Address - Country:US
Practice Address - Phone:335-293-1395
Practice Address - Fax:336-293-1394
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-16
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13059183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1154616308OtherNPPES
NC13059OtherNC BOARD OF PHARMACY LICENSE NUMBER