Healthcare Provider Details

I. General information

NPI: 1477568244
Provider Name (Legal Business Name): VIRGINIA BURTON UPDEGRAVE RPH, BCPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 04/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 W ASH ST
GOLDSBORO NC
27530-1078
US

IV. Provider business mailing address

1401 W ASH ST
GOLDSBORO NC
27530-1078
US

V. Phone/Fax

Practice location:
  • Phone: 919-947-8160
  • Fax:
Mailing address:
  • Phone: 919-947-8160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License Number11309
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: