=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982292744
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEORGE F FETKO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2021
-----------------------------------------------------
Last Update Date | 01/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2508 GRAY ST
-----------------------------------------------------
City | HOPEWELL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23860-5026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-458-3784
-----------------------------------------------------
Fax | 804-458-6450
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13320 LEONARDS LN
-----------------------------------------------------
City | DISPUTANTA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23842-8405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 0202204481
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------