Provider Demographics
NPI:1215219787
Name:AGENE, PETER (B PHARM)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:AGENE
Suffix:
Gender:M
Credentials:B PHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 NIMMO PARKWAY
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456
Mailing Address - Country:US
Mailing Address - Phone:757-427-1655
Mailing Address - Fax:757-427-1514
Practice Address - Street 1:1101 NIMMO PKWY
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-7730
Practice Address - Country:US
Practice Address - Phone:757-427-1655
Practice Address - Fax:757-427-1514
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202207953183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist