Healthcare Provider Details

I. General information

NPI: 1164735395
Provider Name (Legal Business Name): CARL THOMAS DAGENHART JR. B.S., R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 07/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1918 RANDOLPH RD SUITE 120
CHARLOTTE NC
28207-1100
US

IV. Provider business mailing address

1918 RANDOLPH RD SUITE 120
CHARLOTTE NC
28207-1100
US

V. Phone/Fax

Practice location:
  • Phone: 704-342-8180
  • Fax: 704-344-2243
Mailing address:
  • Phone: 704-342-8180
  • Fax: 704-344-2243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5520
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: