Healthcare Provider Details

I. General information

NPI: 1124477351
Provider Name (Legal Business Name): DANIELLE GROOMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 06/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5449 LONGVIEW DR
CROSS LANES WV
25313-1514
US

IV. Provider business mailing address

5449 LONGVIEW DR
CROSS LANES WV
25313-1514
US

V. Phone/Fax

Practice location:
  • Phone: 304-541-0366
  • Fax:
Mailing address:
  • Phone: 304-541-0366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberTT0011411
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: