Provider Demographics
NPI:1922565258
Name:MASSENGILL, HUBERT VERNON JR
Entity type:Individual
Prefix:
First Name:HUBERT
Middle Name:VERNON
Last Name:MASSENGILL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1209
Mailing Address - Street 2:
Mailing Address - City:YANCEYVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27379-1209
Mailing Address - Country:US
Mailing Address - Phone:336-694-4104
Mailing Address - Fax:336-694-5823
Practice Address - Street 1:1493 MAIN ST
Practice Address - Street 2:
Practice Address - City:YANCEYVILLE
Practice Address - State:NC
Practice Address - Zip Code:27379-8793
Practice Address - Country:US
Practice Address - Phone:336-694-4104
Practice Address - Fax:336-694-5823
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC05846183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1194744342Medicaid