Provider Demographics
NPI:1174118152
Name:WOODALL, RICHARD MARK (CPHT-ADV)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:MARK
Last Name:WOODALL
Suffix:
Gender:M
Credentials:CPHT-ADV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 E GROVER ST
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-4035
Mailing Address - Country:US
Mailing Address - Phone:704-487-1971
Mailing Address - Fax:
Practice Address - Street 1:701 E GROVER ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-4035
Practice Address - Country:US
Practice Address - Phone:704-487-1971
Practice Address - Fax:704-487-2811
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC221505000132555183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician