Provider Demographics
NPI:1043974124
Name:MANDULAK, BARBARA
Entity type:Individual
Prefix:
First Name:BARBARA
Middle Name:
Last Name:MANDULAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5830 ARBUTUS TRL
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-1428
Mailing Address - Country:US
Mailing Address - Phone:910-488-5474
Mailing Address - Fax:
Practice Address - Street 1:4861 LOGISTICS AVENUE
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-907-6695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7717183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC000004735104OtherNC DRIVERS LICENSE