Provider Demographics
NPI:1962002295
Name:BANDURCO, OLEG V
Entity Type:Individual
Prefix:
First Name:OLEG
Middle Name:V
Last Name:BANDURCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6819 WALTONS LN
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-6113
Mailing Address - Country:US
Mailing Address - Phone:804-694-0060
Mailing Address - Fax:804-694-0500
Practice Address - Street 1:6819 WALTONS LN
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-6113
Practice Address - Country:US
Practice Address - Phone:804-694-0060
Practice Address - Fax:804-694-0500
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011950183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist