Provider Demographics
NPI:1609143478
Name:HAINER, AUDRA L (PHARMD)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:L
Last Name:HAINER
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 1:626 BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-3261
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:626 BOULEVARD
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-3261
Practice Address - Country:US
Practice Address - Phone:804-520-1571
Practice Address - Fax:804-520-6439
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202209233183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist