Provider Demographics
NPI:1700559945
Name:WALVOORT, HARLEY
Entity Type:Individual
Prefix:
First Name:HARLEY
Middle Name:
Last Name:WALVOORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12058 MONETA RD
Mailing Address - Street 2:
Mailing Address - City:MONETA
Mailing Address - State:VA
Mailing Address - Zip Code:24121-5707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1217 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:VA
Practice Address - Zip Code:24523-2911
Practice Address - Country:US
Practice Address - Phone:540-586-2187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-25
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202219764183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist