Provider Demographics
NPI:1174747711
Name:BLOOD AND CANCER CLINIC, PA
Entity type:Organization
Organization Name:BLOOD AND CANCER CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIRISH
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEVASTHALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-483-8586
Mailing Address - Street 1:PO BOX 53095
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-3095
Mailing Address - Country:US
Mailing Address - Phone:910-483-8586
Mailing Address - Fax:910-483-9212
Practice Address - Street 1:2125 VALLEYGATE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3657
Practice Address - Country:US
Practice Address - Phone:910-483-8586
Practice Address - Fax:910-483-9212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC02701OtherBOARD OF PHARMACY
NC3400936OtherNCPDP NUMBER
NC02699OtherBOARD OF PHARMACY
NC38929OtherLICENSE NUMBER