Provider Demographics
NPI:1144503707
Name:BOMAR, RECIE (RPH)
Entity type:Individual
Prefix:
First Name:RECIE
Middle Name:
Last Name:BOMAR
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 1:1049 IVY POINT CT
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-1812
Mailing Address - Country:US
Mailing Address - Phone:336-416-8639
Mailing Address - Fax:
Practice Address - Street 1:1049 IVY POINT CT
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551-1812
Practice Address - Country:US
Practice Address - Phone:336-416-8639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202004375183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist