Provider Demographics
NPI:1679650352
Name:STREET, NELLIE C (RPH)
Entity Type:Individual
Prefix:
First Name:NELLIE
Middle Name:C
Last Name:STREET
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:RR 2 BOX 413
Mailing Address - Street 2:
Mailing Address - City:HONAKER
Mailing Address - State:VA
Mailing Address - Zip Code:24260-9501
Mailing Address - Country:US
Mailing Address - Phone:276-859-2854
Mailing Address - Fax:
Practice Address - Street 1:110 WEST MAIN
Practice Address - Street 2:SUITE 1
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266
Practice Address - Country:US
Practice Address - Phone:276-889-1919
Practice Address - Fax:276-889-4635
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202010455183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist