Provider Demographics
NPI:1376143966
Name:BALAS, DEVON
Entity Type:Individual
Prefix:
First Name:DEVON
Middle Name:
Last Name:BALAS
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 1:3709 CARDINAL LN
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-3617
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6259 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-2610
Practice Address - Country:US
Practice Address - Phone:757-483-9833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-01
Last Update Date:2020-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202211934333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy