Provider Demographics
NPI:1538762190
Name:VAUGHAN, CRYSTAL M PEEBLES
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:M PEEBLES
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:MICHELLE
Other - Last Name:PEEBLES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMACIST
Mailing Address - Street 1:11301 MIDLOTHIAN TPKE
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-4715
Mailing Address - Country:US
Mailing Address - Phone:804-897-5245
Mailing Address - Fax:804-893-8392
Practice Address - Street 1:11301 MIDLOTHIAN TPKE
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4715
Practice Address - Country:US
Practice Address - Phone:804-897-5245
Practice Address - Fax:804-893-8392
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202009764183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist