Healthcare Provider Details

I. General information

NPI: 1114148905
Provider Name (Legal Business Name): MS. VIRGINIA WILLETTE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 TOWNSEND AVE
BERLIN NJ
08009-9011
US

IV. Provider business mailing address

3 FIRETHORNE RD
CHERRY HILL NJ
08003-1239
US

V. Phone/Fax

Practice location:
  • Phone: 856-322-3030
  • Fax:
Mailing address:
  • Phone: 856-751-2842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28R102495600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: