Provider Demographics
NPI:1225811334
Name:HORTON, SELENA DAJAI
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:DAJAI
Last Name:HORTON
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 1:403 STOCKTON ST APT 4133
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-4352
Mailing Address - Country:US
Mailing Address - Phone:520-238-1952
Mailing Address - Fax:
Practice Address - Street 1:919 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-2211
Practice Address - Country:US
Practice Address - Phone:434-392-3104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202221478183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist