Provider Demographics
NPI:1184957433
Name:ALLEN, MIRANDA LANE (PHARM D)
Entity type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:LANE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:DR
Other - First Name:MIRANDA
Other - Middle Name:ASHLEY
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARM D
Mailing Address - Street 1:2509 WINGFIELD RD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23518-4566
Mailing Address - Country:US
Mailing Address - Phone:423-794-6286
Mailing Address - Fax:
Practice Address - Street 1:620 JOHN PAUL JONES CIR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708-2111
Practice Address - Country:US
Practice Address - Phone:423-794-6286
Practice Address - Fax:757-953-0865
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-17
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33676183500000X
MSE-010562183500000X
VA0202210317183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist