Healthcare Provider Details

I. General information

NPI: 1689075152
Provider Name (Legal Business Name): UNDRA GRAVES-GUYTON PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2014
Last Update Date: 09/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 LOISDALE CT
SPRINGFIELD VA
22150-9998
US

IV. Provider business mailing address

5601 LOISDALE CT
SPRINGFIELD VA
22150-9998
US

V. Phone/Fax

Practice location:
  • Phone: 703-922-1014
  • Fax: 703-922-1016
Mailing address:
  • Phone: 703-922-1014
  • Fax: 703-922-1016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202210816
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS015906
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: