Provider Demographics
NPI:1780280040
Name:SHOWALTER, NELSON
Entity type:Individual
Prefix:
First Name:NELSON
Middle Name:
Last Name:SHOWALTER
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:PO BOX 245
Mailing Address - Street 2:
Mailing Address - City:BROADWAY
Mailing Address - State:VA
Mailing Address - Zip Code:22815-0245
Mailing Address - Country:US
Mailing Address - Phone:540-578-0126
Mailing Address - Fax:
Practice Address - Street 1:169 EAST SPRINGBROOK ROAD
Practice Address - Street 2:
Practice Address - City:BROADWAY
Practice Address - State:VA
Practice Address - Zip Code:22815-2281
Practice Address - Country:US
Practice Address - Phone:540-896-3251
Practice Address - Fax:540-896-5411
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202004083183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist