Healthcare Provider Details

I. General information

NPI: 1639436660
Provider Name (Legal Business Name): MARY BOSEMAN POWELL PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2012
Last Update Date: 04/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 NEALY AVENUE 633D MEDICAL GROUP
JOINT BASE LANGLEY-EUSTIS VA
23665-2040
US

IV. Provider business mailing address

77 NEALY AVENUE 633D MEDICAL GROUP
JOINT BASE LANGLEY-EUSTIS VA
23665-2040
US

V. Phone/Fax

Practice location:
  • Phone: 757-225-7630
  • Fax:
Mailing address:
  • Phone: 757-225-7630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202207258
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17996
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: