Healthcare Provider Details

I. General information

NPI: 1851464465
Provider Name (Legal Business Name): JOHN W BASS JR. RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

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

4121 HALIFAX ROAD
SOUTH BOSTON VA
24592
US

IV. Provider business mailing address

PO BOX 788 469 LAKESIDE DRIVE
HALIFAX VA
24558
US

V. Phone/Fax

Practice location:
  • Phone: 434-575-0511
  • Fax: 434-575-1366
Mailing address:
  • Phone: 434-476-6629
  • Fax: 434-575-1366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202003779
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: