Provider Demographics
NPI:1639281900
Name:NALLE PHARMACY
Entity Type:Organization
Organization Name:NALLE PHARMACY
Other - Org Name:NALLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAGENHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-342-8180
Mailing Address - Street 1:1918 RANDOLPH RD
Mailing Address - Street 2:STE 120
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1918 RANDOLPH RD
Practice Address - Street 2:STE 120
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1100
Practice Address - Country:US
Practice Address - Phone:704-342-8180
Practice Address - Fax:704-344-2243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC75653336C0003X
3336C0004X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3421687OtherOTHER ID NUMBER
NC0609324Medicaid
NC0609324Medicaid