Provider Demographics
NPI:1396405882
Name:CORDILL, BRAXTON TYLER (PHARMD)
Entity Type:Individual
Prefix:
First Name:BRAXTON
Middle Name:TYLER
Last Name:CORDILL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:COEBURN
Mailing Address - State:VA
Mailing Address - Zip Code:24230-3529
Mailing Address - Country:US
Mailing Address - Phone:276-395-5396
Mailing Address - Fax:
Practice Address - Street 1:101 LAUREL AVE
Practice Address - Street 2:
Practice Address - City:COEBURN
Practice Address - State:VA
Practice Address - Zip Code:24230-3529
Practice Address - Country:US
Practice Address - Phone:276-395-5396
Practice Address - Fax:276-395-7928
Is Sole Proprietor?:No
Enumeration Date:2021-12-23
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202220134183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist