Healthcare Provider Details

I. General information

NPI: 1982994604
Provider Name (Legal Business Name): MR. XIAOHONG BAO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: KEVIN BAO

II. Dates (important events)

Enumeration Date: 04/14/2011
Last Update Date: 04/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 MAIN STREET RITE AID PHARMACY
STUART VA
24171
US

IV. Provider business mailing address

2523 WILLOWLAWN ST
ROANOKE VA
24018-2526
US

V. Phone/Fax

Practice location:
  • Phone: 276-694-4034
  • Fax:
Mailing address:
  • Phone: 540-989-1390
  • Fax: 540-989-1390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202012832
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: