Provider Demographics
NPI:1639463664
Name:WYNNE, REBECCA TAYLOR (RPH)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:TAYLOR
Last Name:WYNNE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 GREENBRIER PKWY
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-0605
Mailing Address - Country:US
Mailing Address - Phone:757-547-5802
Mailing Address - Fax:757-547-5802
Practice Address - Street 1:1316 GREENBRIER PKWY
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-0605
Practice Address - Country:US
Practice Address - Phone:757-547-5802
Practice Address - Fax:757-547-5802
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202010358183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0202010358OtherBOARD OF PHARMACY LISCENCE