Healthcare Provider Details

I. General information

NPI: 1619049525
Provider Name (Legal Business Name): ANNE CARLISLE KIDD RPH BCPP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1902 BRAEBURN DR
SALEM VA
24153-7304
US

IV. Provider business mailing address

1624 SUNBERRY CIR
ROANOKE VA
24018-7689
US

V. Phone/Fax

Practice location:
  • Phone: 540-772-2835
  • Fax:
Mailing address:
  • Phone: 540-989-7319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License Number0202007158
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: