Provider Demographics
NPI:1093353047
Name:BLACK, VIRGINIA LEO (RPH)
Entity Type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:LEO
Last Name:BLACK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6010 CASTLE RD
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-9310
Mailing Address - Country:US
Mailing Address - Phone:601-636-1718
Mailing Address - Fax:
Practice Address - Street 1:6010 CASTLE RD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-9310
Practice Address - Country:US
Practice Address - Phone:601-636-1718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-19
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-05403183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist