=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790453447
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTIE A PHIPPS RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2021
-----------------------------------------------------
Last Update Date | 08/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 185 S MAIN ST
-----------------------------------------------------
City | HILLSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24343-1502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-728-2731
-----------------------------------------------------
Fax | 276-728-3502
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 266 CHIHUAHUA RUN LANE
-----------------------------------------------------
City | GALAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-236-4622
-----------------------------------------------------
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 | 0202011226
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------