MEDICARE: DR. TIASARA MACK PHARMD

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	1835G0303X	Geriatric Pharmacist	0202215182	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0202215182	OTHER	VA	VIRGINIA BOARD OF PHARMACY LICENSE NUMBER

General Provider Information

NPI Number	:	1699377135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIASARA MACK PHARMD

Provider Business Mailing Address
First Line	:	1872 SOMERTON PL
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-6944
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1832 KEMPSVILLE RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-6861
Country	:	US
Telephone Number	:	757-278-2573
Fax Number	:

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

Provider Enumeration Date	:	11/10/2020
Last Update Date	:	11/10/2020

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