Provider Demographics
NPI:1184310419
Name:SMALLWOOD, PERRIS DWAYNE (CPHT)
Entity type:Individual
Prefix:
First Name:PERRIS
Middle Name:DWAYNE
Last Name:SMALLWOOD
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:377 TYLER AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-4109
Mailing Address - Country:US
Mailing Address - Phone:757-818-1074
Mailing Address - Fax:
Practice Address - Street 1:3701 KECOUGHTAN RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23669-4405
Practice Address - Country:US
Practice Address - Phone:757-728-2913
Practice Address - Fax:757-728-3886
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0230022698183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician