=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770501785
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLARENCE MASON MITCHELL JR. BSPHARM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 HOSPITAL DR TCRH PHARMACY DEPT
-----------------------------------------------------
City | GALAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24333-2227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-236-4981
-----------------------------------------------------
Fax | 276-236-1709
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 124 HIGHLAND AVE
-----------------------------------------------------
City | GALAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24333-2602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-236-2452
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 0202004477
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------