Provider Demographics
NPI:1174119788
Name:MULLINS, GREGORY BRIAN (RPH)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:BRIAN
Last Name:MULLINS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1480
Mailing Address - Street 2:
Mailing Address - City:POUND
Mailing Address - State:VA
Mailing Address - Zip Code:24279-1480
Mailing Address - Country:US
Mailing Address - Phone:276-870-4759
Mailing Address - Fax:276-796-2202
Practice Address - Street 1:11231 INDIAN CREEK RD
Practice Address - Street 2:
Practice Address - City:POUND
Practice Address - State:VA
Practice Address - Zip Code:24279
Practice Address - Country:US
Practice Address - Phone:276-796-2200
Practice Address - Fax:276-796-2202
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02020114283336C0003X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010266238Medicaid
KY7100266980Medicaid