Provider Demographics
NPI:1801146246
Name:LABAUCH, PHILLIP TYLER (PHARMD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:TYLER
Last Name:LABAUCH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2413 GREENLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-5019
Mailing Address - Country:US
Mailing Address - Phone:704-222-1424
Mailing Address - Fax:
Practice Address - Street 1:1706 S CANNON BLVD
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28083-6104
Practice Address - Country:US
Practice Address - Phone:704-933-6337
Practice Address - Fax:704-933-6374
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37545183500000X
NC19024183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC19024OtherPHARMACIST LICENSE
SC37545OtherPHARMACIST LICENSE