Provider Demographics
NPI:1023638178
Name:SHATALOV, ALEXANDER (PHARMD)
Entity type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:
Last Name:SHATALOV
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 PETERS CREEK PKWY APT 326
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-3687
Mailing Address - Country:US
Mailing Address - Phone:803-429-4347
Mailing Address - Fax:
Practice Address - Street 1:1433 LEWISVILLE CLEMMONS RD
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-9713
Practice Address - Country:US
Practice Address - Phone:336-712-0663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-19
Last Update Date:2021-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29102183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC29102OtherNORTH CAROLINA BOARD OF PHARMACY