Healthcare Provider Details

I. General information

NPI: 1083377519
Provider Name (Legal Business Name): MARK SHAWN CORDLE II PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2021
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 NEWS RD
WILLIAMSBURG VA
23188-7803
US

IV. Provider business mailing address

113 CARAN RD
WILLIAMSBURG VA
23185-2934
US

V. Phone/Fax

Practice location:
  • Phone: 757-220-1287
  • Fax:
Mailing address:
  • Phone: 304-573-5484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202219987
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: