Healthcare Provider Details

I. General information

NPI: 1760701759
Provider Name (Legal Business Name): AVERY GATHERS AVERY GATHERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2010
Last Update Date: 05/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 W 21ST ST
NORFOLK VA
23517-1985
US

IV. Provider business mailing address

3537 CRIOLLO DR
VIRGINIA BEACH VA
23453-2247
US

V. Phone/Fax

Practice location:
  • Phone: 757-625-6073
  • Fax:
Mailing address:
  • Phone: 757-468-1602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0201001461
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: