Provider Demographics
NPI:1558612192
Name:PENG, QIU (PHARMD)
Entity Type:Individual
Prefix:
First Name:QIU
Middle Name:
Last Name:PENG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3970 VALLEY GATEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-6773
Mailing Address - Country:US
Mailing Address - Phone:540-977-6481
Mailing Address - Fax:
Practice Address - Street 1:137 NORTH ST
Practice Address - Street 2:
Practice Address - City:HOULTON
Practice Address - State:ME
Practice Address - Zip Code:04730-1832
Practice Address - Country:US
Practice Address - Phone:207-532-6876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-23
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR12539183500000X
VA02022120531835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist