Healthcare Provider Details

I. General information

NPI: 1629663828
Provider Name (Legal Business Name): PEYTON TAYLOR JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2021
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1956 SANDY HOOK RD
GOOCHLAND VA
23063-3107
US

IV. Provider business mailing address

PO BOX 166
GOOCHLAND VA
23063-0166
US

V. Phone/Fax

Practice location:
  • Phone: 804-556-3607
  • Fax:
Mailing address:
  • Phone: 804-556-3607
  • Fax: 804-556-2414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202005750
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: