Provider Demographics
NPI:1164407177
Name:STREET, RALPH LEE (RPH)
Entity Type:Individual
Prefix:MR
First Name:RALPH
Middle Name:LEE
Last Name:STREET
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 1:459 GRAND VIEW CT
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:VA
Mailing Address - Zip Code:24280-3510
Mailing Address - Country:US
Mailing Address - Phone:276-880-3162
Mailing Address - Fax:276-889-4635
Practice Address - Street 1:110 W MAIN ST
Practice Address - Street 2:SUITE #1
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266-4430
Practice Address - Country:US
Practice Address - Phone:276-889-1919
Practice Address - Fax:276-889-4635
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202005137183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist