Provider Demographics
NPI:1245608678
Name:HARRIS, PAM
Entity Type:Individual
Prefix:
First Name:PAM
Middle Name:
Last Name:HARRIS
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 1:967C E STUART DR
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-2407
Mailing Address - Country:US
Mailing Address - Phone:276-236-1120
Mailing Address - Fax:276-236-1123
Practice Address - Street 1:967C E STUART DR
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2407
Practice Address - Country:US
Practice Address - Phone:276-236-1120
Practice Address - Fax:276-236-1123
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-02
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202007182183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist