Provider Demographics
NPI:1124381165
Name:MACK, RICHARD THOMAS (RPH)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:THOMAS
Last Name:MACK
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 1:103 IVY CREEK LN
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-2384
Mailing Address - Country:US
Mailing Address - Phone:704-230-1892
Mailing Address - Fax:
Practice Address - Street 1:3111 TAYLORSVILLE HWY
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-2964
Practice Address - Country:US
Practice Address - Phone:704-873-1934
Practice Address - Fax:704-873-7925
Is Sole Proprietor?:No
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC07082183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist