Provider Demographics
NPI:1922561596
Name:BALLENTINE, LYDIA PRATHER (RPH)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:PRATHER
Last Name:BALLENTINE
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 1:8575 MAGELLAN PKWY STE 1000
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-1164
Mailing Address - Country:US
Mailing Address - Phone:804-229-2352
Mailing Address - Fax:
Practice Address - Street 1:8575 MAGELLAN PKWY STE 1000
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227-1164
Practice Address - Country:US
Practice Address - Phone:804-229-2352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA020200092711835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric