Provider Demographics
NPI:1285234880
Name:LASTER, RAY
Entity type:Individual
Prefix:
First Name:RAY
Middle Name:
Last Name:LASTER
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 1:21531 MARKET CTR
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24202-1808
Mailing Address - Country:US
Mailing Address - Phone:276-466-0319
Mailing Address - Fax:276-466-0782
Practice Address - Street 1:21531 MARKET CTR
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24202-1808
Practice Address - Country:US
Practice Address - Phone:276-466-0319
Practice Address - Fax:276-466-0782
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-01
Last Update Date:2020-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011079183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist