Provider Demographics
NPI:1992360150
Name:CHABOT, MARK PAUL (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:PAUL
Last Name:CHABOT
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 MISTLAND TRL
Mailing Address - Street 2:
Mailing Address - City:RUCKERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22968-3094
Mailing Address - Country:US
Mailing Address - Phone:434-962-3803
Mailing Address - Fax:
Practice Address - Street 1:2415 LEE STREET PHARMACY- 800674
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0001
Practice Address - Country:US
Practice Address - Phone:434-465-5784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-03
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03314176183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03314176OtherOSBOP
VA0202-012862OtherVSBOP