Provider Demographics
NPI:1093155202
Name:SLATE, BRACK EDWARD (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:BRACK
Middle Name:EDWARD
Last Name:SLATE
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 E JACKSON ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GATE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:24251-3418
Mailing Address - Country:US
Mailing Address - Phone:276-386-3821
Mailing Address - Fax:276-386-7582
Practice Address - Street 1:119 E JACKSON ST
Practice Address - Street 2:SUITE 101
Practice Address - City:GATE CITY
Practice Address - State:VA
Practice Address - Zip Code:24251-3418
Practice Address - Country:US
Practice Address - Phone:276-386-3821
Practice Address - Fax:276-386-7582
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202001691183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist