Provider Demographics
NPI:1649234675
Name:PACK, WOODROW EDWARD JR
Entity Type:Individual
Prefix:
First Name:WOODROW
Middle Name:EDWARD
Last Name:PACK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 DIAMONDVIEW LOOP
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-2115
Mailing Address - Country:US
Mailing Address - Phone:276-236-9013
Mailing Address - Fax:276-236-4149
Practice Address - Street 1:246 DIAMONDVIEW LOOP
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2115
Practice Address - Country:US
Practice Address - Phone:276-236-9013
Practice Address - Fax:276-236-4149
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202004994183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0008513333Medicaid