Provider Demographics
NPI:1366244634
Name:BASS, DAVID LANE JR (RPH)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:LANE
Last Name:BASS
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 WINDWARD SHORE DR
Mailing Address - Street 2:
Mailing Address - City:VA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-1728
Mailing Address - Country:US
Mailing Address - Phone:757-577-1024
Mailing Address - Fax:
Practice Address - Street 1:525 W 21ST ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-1985
Practice Address - Country:US
Practice Address - Phone:757-625-6073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-26
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202010251183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist