Provider Demographics
NPI:1285932129
Name:DODOO, JACOBUS VIGGO (M PHARM)
Entity type:Individual
Prefix:MR
First Name:JACOBUS
Middle Name:VIGGO
Last Name:DODOO
Suffix:
Gender:M
Credentials:M PHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 E FRANKLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4059
Mailing Address - Country:US
Mailing Address - Phone:980-320-1533
Mailing Address - Fax:980-320-1534
Practice Address - Street 1:1401 E FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4059
Practice Address - Country:US
Practice Address - Phone:980-320-1533
Practice Address - Fax:980-320-1534
Is Sole Proprietor?:No
Enumeration Date:2011-03-01
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18801183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1932586351Medicaid