Provider Demographics
NPI:1710587654
Name:DORSEY, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DORSEY
Suffix:
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 1:10 SOMERSET AVE
Mailing Address - Street 2:
Mailing Address - City:DALEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24083-1118
Mailing Address - Country:US
Mailing Address - Phone:540-314-5023
Mailing Address - Fax:
Practice Address - Street 1:1455 TOWNE SQUARE BLVD NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-1612
Practice Address - Country:US
Practice Address - Phone:540-527-2364
Practice Address - Fax:540-527-2363
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011734183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist