Provider Demographics
NPI:1700179975
Name:MCGAHEY, JACK OLIVER
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:OLIVER
Last Name:MCGAHEY
Suffix:
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 1:5706 WYALONG DR
Mailing Address - Street 2:HARRIS TEETER #174
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-7843
Mailing Address - Country:US
Mailing Address - Phone:704-545-4106
Mailing Address - Fax:704-545-9526
Practice Address - Street 1:5706 WYALONG DR
Practice Address - Street 2:HARRIS TEETER #174
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-7843
Practice Address - Country:US
Practice Address - Phone:704-545-4106
Practice Address - Fax:704-545-9526
Is Sole Proprietor?:No
Enumeration Date:2011-05-22
Last Update Date:2011-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15393183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0601006Medicaid