Provider Demographics
NPI:1699067710
Name:LANE, JEFFREY FULTON (RPH)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:FULTON
Last Name:LANE
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 1:6544 CREEK RD
Mailing Address - Street 2:
Mailing Address - City:HAYES
Mailing Address - State:VA
Mailing Address - Zip Code:23072-3218
Mailing Address - Country:US
Mailing Address - Phone:804-642-6354
Mailing Address - Fax:
Practice Address - Street 1:1303 JAMESTOWN RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-3333
Practice Address - Country:US
Practice Address - Phone:757-220-1355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-08
Last Update Date:2011-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202005254183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist