Provider Demographics
NPI:1689075152
Name:GRAVES-GUYTON, UNDRA (PHARM D)
Entity Type:Individual
Prefix:
First Name:UNDRA
Middle Name:
Last Name:GRAVES-GUYTON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 LOISDALE CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22150-9998
Mailing Address - Country:US
Mailing Address - Phone:703-922-1014
Mailing Address - Fax:703-922-1016
Practice Address - Street 1:5601 LOISDALE CT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-9998
Practice Address - Country:US
Practice Address - Phone:703-922-1014
Practice Address - Fax:703-922-1016
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202210816183500000X
AZS015906183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist