Provider Demographics
NPI:1861492845
Name:LARGE-FOX, AUTUMN (RPH, PHARMD, CDE)
Entity Type:Individual
Prefix:DR
First Name:AUTUMN
Middle Name:
Last Name:LARGE-FOX
Suffix:
Gender:F
Credentials:RPH, PHARMD, CDE
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 777
Mailing Address - Street 2:
Mailing Address - City:BIG STONE GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24219-0777
Mailing Address - Country:US
Mailing Address - Phone:276-523-1713
Mailing Address - Fax:276-523-2931
Practice Address - Street 1:14 E 27TH ST N
Practice Address - Street 2:SUITE 1
Practice Address - City:BIG STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24219-3624
Practice Address - Country:US
Practice Address - Phone:276-523-1713
Practice Address - Fax:276-523-2931
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202206469183500000X
NC16915183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0202206469OtherPHARMACIST LICENSE NUMBER
NC16915OtherNORTH CAROLINA PHARMACIST