Provider Demographics
NPI:1043714371
Name:YOUR PERSONAL PHARMACIST, PLLC
Entity type:Organization
Organization Name:YOUR PERSONAL PHARMACIST, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:757-286-2005
Mailing Address - Street 1:3508 BANANA LN
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-3489
Mailing Address - Country:US
Mailing Address - Phone:757-286-2005
Mailing Address - Fax:
Practice Address - Street 1:3508 BANANA LN
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3489
Practice Address - Country:US
Practice Address - Phone:757-286-2005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202212308333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy