Provider Demographics
NPI:1932418357
Name:AUTRY, DALE (PHARMACIST)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:
Last Name:AUTRY
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3625 S COLLEGE RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-2003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3625 SOUTH COLLEGE ROAD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412
Practice Address - Country:US
Practice Address - Phone:910-395-8248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16329183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC06050000Medicaid