Healthcare Provider Details

I. General information

NPI: 1568780401
Provider Name (Legal Business Name): ANDREW PUNZALAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2010
Last Update Date: 05/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5036 FERRELL PKWY
VIRGINIA BEACH VA
23464-8867
US

IV. Provider business mailing address

5036 FERRELL PKWY
VIRGINIA BEACH VA
23464-8867
US

V. Phone/Fax

Practice location:
  • Phone: 757-495-3088
  • Fax: 757-495-6581
Mailing address:
  • Phone: 757-495-3088
  • Fax: 757-495-6581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202010435
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: