Provider Demographics
NPI:1487371118
Name:PRILLAMAN, MICHAEL G (RPH)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:PRILLAMAN
Suffix:
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 1:1200 IVY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-4464
Mailing Address - Country:US
Mailing Address - Phone:434-841-2857
Mailing Address - Fax:
Practice Address - Street 1:1200 IVY LAKE DR
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551-4464
Practice Address - Country:US
Practice Address - Phone:434-841-2857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202007925183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist