Provider Demographics
NPI:1205413119
Name:GARVIN, JADEN TYRELL (EXCPT)
Entity Type:Individual
Prefix:
First Name:JADEN
Middle Name:TYRELL
Last Name:GARVIN
Suffix:
Gender:M
Credentials:EXCPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:946 DUNBAR ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23504-2701
Mailing Address - Country:US
Mailing Address - Phone:757-389-2688
Mailing Address - Fax:
Practice Address - Street 1:1832 KEMPSVILLE RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-6861
Practice Address - Country:US
Practice Address - Phone:757-278-2573
Practice Address - Fax:757-278-2567
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0230033833183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist