Provider Demographics
NPI:1477837417
Name:MCNULTY, CHARLES MICHAEL (R PH)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MICHAEL
Last Name:MCNULTY
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:PROF
Other - First Name:CHARLES
Other - Middle Name:MICHAEL
Other - Last Name:MCNULTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:R PH
Mailing Address - Street 1:4625 SUMMER AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38122-4137
Mailing Address - Country:US
Mailing Address - Phone:901-682-1026
Mailing Address - Fax:901-684-1430
Practice Address - Street 1:4625 SUMMER AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38122-4137
Practice Address - Country:US
Practice Address - Phone:901-682-1026
Practice Address - Fax:901-684-1430
Is Sole Proprietor?:No
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6200183500000X
MSE-06200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4424204OtherNABP