Healthcare Provider Details

I. General information

NPI: 1588324404
Provider Name (Legal Business Name): RODERICK VAUGHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2021
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3323 13TH ST SE APT 4
WASHINGTON DC
20032-4533
US

IV. Provider business mailing address

3323 13TH ST SE APT 4
WASHINGTON DC
20032-4533
US

V. Phone/Fax

Practice location:
  • Phone: 202-465-2845
  • Fax:
Mailing address:
  • Phone: 202-465-2845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number30158000
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: