MEDICARE: MR. WILLIAM LOUIS TATUM JR. BS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	05749	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0004449861	OTHER	VA	STATE TAX ID
2	4820999	OTHER	VA	NABP

General Provider Information

NPI Number	:	1326064833
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WILLIAM LOUIS TATUM JR. BS

Provider Business Mailing Address
First Line	:	19071 LAKESIDE DR
Second Line	:
City	:	COURTLAND
State	:	VA
Zip	:	23837-2633
Country	:	US
Telephone Number	:	757-657-6369
Fax Number	:

Provider Business Practice Location Address
First Line	:	425 W WASHINGTON ST
Second Line	:
City	:	SUFFOLK
State	:	VA
Zip	:	23434-5320
Country	:	US
Telephone Number	:	757-925-2013
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2006
Last Update Date	:	07/08/2007

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