Provider Demographics
NPI:1215269774
Name:MACK, BRIAN J (RPH)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:MACK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1549 ROUTE 9
Mailing Address - Street 2:WALMART PHARMACY
Mailing Address - City:HALFMOON
Mailing Address - State:NY
Mailing Address - Zip Code:12065-5603
Mailing Address - Country:US
Mailing Address - Phone:518-373-5732
Mailing Address - Fax:518-373-5753
Practice Address - Street 1:1549 ROUTE 9
Practice Address - Street 2:WALMART PHARMACY
Practice Address - City:HALFMOON
Practice Address - State:NY
Practice Address - Zip Code:12065-5603
Practice Address - Country:US
Practice Address - Phone:518-373-5732
Practice Address - Fax:518-373-5753
Is Sole Proprietor?:No
Enumeration Date:2010-02-09
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044401183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist