MEDICARE: PETER AGENE B. PHARM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	0202207953	VA

General Provider Information

NPI Number	:	1215219787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER AGENE B. PHARM

Provider Business Mailing Address
First Line	:	1101 NIMMO PARKWAY
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456
Country	:	US
Telephone Number	:	757-427-1655
Fax Number	:	757-427-1514

Provider Business Practice Location Address
First Line	:	1101 NIMMO PKWY
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-7730
Country	:	US
Telephone Number	:	757-427-1655
Fax Number	:	757-427-1514

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2011
Last Update Date	:	09/12/2011

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