Healthcare Provider Details

I. General information

NPI: 1497143226
Provider Name (Legal Business Name): STEPHANIE EGEMOLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2015
Last Update Date: 01/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

671 J CLYDE MORRIS BLVD
NEWPORT NEWS VA
23601-1839
US

IV. Provider business mailing address

30 KINGS WAY APT 304
HAMPTON VA
23669-3503
US

V. Phone/Fax

Practice location:
  • Phone: 757-596-0037
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202213542
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: