Healthcare Provider Details

I. General information

NPI: 1164407177
Provider Name (Legal Business Name): RALPH LEE STREET RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 W MAIN ST SUITE #1
LEBANON VA
24266-4430
US

IV. Provider business mailing address

459 GRAND VIEW CT
ROSEDALE VA
24280-3510
US

V. Phone/Fax

Practice location:
  • Phone: 276-889-1919
  • Fax: 276-889-4635
Mailing address:
  • Phone: 276-880-3162
  • Fax: 276-889-4635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202005137
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: