Provider Demographics
NPI:1821389412
Name:VANCE, JUSTIN DAVID (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:DAVID
Last Name:VANCE
Suffix:
Gender:M
Credentials:PHARMD
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 286
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25053-0286
Mailing Address - Country:US
Mailing Address - Phone:304-369-0152
Mailing Address - Fax:304-369-9672
Practice Address - Street 1:406 SMOOT AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:WV
Practice Address - Zip Code:25053-0286
Practice Address - Country:US
Practice Address - Phone:304-369-0152
Practice Address - Fax:304-369-9672
Is Sole Proprietor?:No
Enumeration Date:2011-04-29
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0007273183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist