Provider Demographics
NPI:1427055623
Name:FAIRCLOTH, VERNON ALLEN (RPH)
Entity type:Individual
Prefix:
First Name:VERNON
Middle Name:ALLEN
Last Name:FAIRCLOTH
Suffix:
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 1:2308 COLGATE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-5304
Mailing Address - Country:US
Mailing Address - Phone:910-907-7427
Mailing Address - Fax:
Practice Address - Street 1:WAMC STOP A
Practice Address - Street 2:2817 REILLY ROAD MCXC PH
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-907-7497
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6558183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist