Healthcare Provider Details

I. General information

NPI: 1952239048
Provider Name (Legal Business Name): UPPER MATTAPONI INDIAN TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7453 HARGETT BLVD
GLOUCESTER VA
23061-2038
US

IV. Provider business mailing address

7453 HARGETT BLVD
GLOUCESTER VA
23061-2038
US

V. Phone/Fax

Practice location:
  • Phone: 804-694-3999
  • Fax: 800-853-2692
Mailing address:
  • Phone: 804-694-3999
  • Fax: 804-769-2014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY MCQUEEN
Title or Position: DIRECTOR OF CREDENTIALING AND COMPL
Credential:
Phone: 804-535-0145