Healthcare Provider Details

I. General information

NPI: 1689276909
Provider Name (Legal Business Name): JOHN BOOKER IV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2020
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 MOUNT CROSS RD
DANVILLE VA
24540-4065
US

IV. Provider business mailing address

3037 WESTOVER DR
DANVILLE VA
24541-5447
US

V. Phone/Fax

Practice location:
  • Phone: 434-799-6813
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202007759
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: