Provider Demographics
NPI:1205408259
Name:JUSTUS, HAILEY
Entity Type:Individual
Prefix:
First Name:HAILEY
Middle Name:
Last Name:JUSTUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1988
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266-1988
Mailing Address - Country:US
Mailing Address - Phone:276-889-3800
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:276-889-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-10
Last Update Date:2021-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202219709183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist