Healthcare Provider Details

I. General information

NPI: 1295740835
Provider Name (Legal Business Name): GLOUCESTER MATHEWS CARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 09/19/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6031 INDUSTRIAL DR
GLOUCESTER VA
23061-3767
US

IV. Provider business mailing address

6031 INDUSTRIAL DR
GLOUCESTER VA
23061-3767
US

V. Phone/Fax

Practice location:
  • Phone: 804-642-9515
  • Fax: 804-684-3691
Mailing address:
  • Phone: 804-642-9515
  • Fax: 804-684-3691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number0201003539
License Number StateVA

VIII. Authorized Official

Name: KERRY DANACEAU
Title or Position: PIC
Credential:
Phone: 804-642-9515