Provider Demographics
NPI:1457641797
Name:HADIMANI, MALLINATH B (PHD, RPH)
Entity Type:Individual
Prefix:DR
First Name:MALLINATH
Middle Name:B
Last Name:HADIMANI
Suffix:
Gender:M
Credentials:PHD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 REYNOLDA RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-2229
Mailing Address - Country:US
Mailing Address - Phone:336-924-9366
Mailing Address - Fax:
Practice Address - Street 1:3601 REYNOLDA RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-2229
Practice Address - Country:US
Practice Address - Phone:336-924-9366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2012-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20916183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist