Provider Demographics
NPI:1790453447
Name:PHIPPS, MATTIE A (RPH)
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:A
Last Name:PHIPPS
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 1:266 CHIHUAHUA RUN LANE
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333
Mailing Address - Country:US
Mailing Address - Phone:276-236-4622
Mailing Address - Fax:
Practice Address - Street 1:185 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HILLSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24343-1502
Practice Address - Country:US
Practice Address - Phone:276-728-2731
Practice Address - Fax:276-728-3502
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011226183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty