Provider Demographics
NPI:1770173445
Name:SAMPLE, CALEB BRYANT
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:BRYANT
Last Name:SAMPLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 GRAND VIEW CT
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:VA
Mailing Address - Zip Code:24280-3597
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:159 PITTSTON RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266-4630
Practice Address - Country:US
Practice Address - Phone:276-889-5914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202219104183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist