MEDICARE: LUCILLE TUBANDT R.PH.

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	0202211588	VA

General Provider Information

NPI Number	:	1962862912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUCILLE TUBANDT R.PH.

Provider Business Mailing Address
First Line	:	6300 MADDOX BLVD
Second Line	:
City	:	CHINCOTEAGUE
State	:	VA
Zip	:	23336-2617
Country	:	US
Telephone Number	:	757-336-3115
Fax Number	:

Provider Business Practice Location Address
First Line	:	6300 MADDOX BLVD
Second Line	:
City	:	CHINCOTEAGUE
State	:	VA
Zip	:	23336-2617
Country	:	US
Telephone Number	:	757-336-3115
Fax Number	:

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

Provider Enumeration Date	:	03/03/2016
Last Update Date	:	03/03/2016

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