Provider Demographics
NPI:1780230649
Name:HAIRSTON, MARK JOSEPH (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:JOSEPH
Last Name:HAIRSTON
Suffix:
Gender:M
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:PO BOX 43
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23927-0043
Mailing Address - Country:US
Mailing Address - Phone:434-374-2851
Mailing Address - Fax:434-374-2851
Practice Address - Street 1:610 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CHASE CITY
Practice Address - State:VA
Practice Address - Zip Code:23924-1133
Practice Address - Country:US
Practice Address - Phone:434-372-4175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19378183500000X
VA0202012515183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist