Healthcare Provider Details

I. General information

NPI: 1437083763
Provider Name (Legal Business Name): HENRY BRODERICK PACK IV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7738 RICHMOND HWY
APPOMATTOX VA
24522-9883
US

IV. Provider business mailing address

7738 RICHMOND HWY
APPOMATTOX VA
24522-9883
US

V. Phone/Fax

Practice location:
  • Phone: 434-352-5213
  • Fax:
Mailing address:
  • Phone: 434-352-5213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202011108
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: