Provider Demographics
NPI:1962892638
Name:RUFFIN, TIERNEY CHANEL
Entity type:Individual
Prefix:MISS
First Name:TIERNEY
Middle Name:CHANEL
Last Name:RUFFIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 SOUTHPARK BLVD
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-3606
Mailing Address - Country:US
Mailing Address - Phone:804-520-2280
Mailing Address - Fax:804-431-3211
Practice Address - Street 1:721 SOUTHPARK BLVD
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-3606
Practice Address - Country:US
Practice Address - Phone:804-520-2280
Practice Address - Fax:804-431-3211
Is Sole Proprietor?:No
Enumeration Date:2015-02-02
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0230010112183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician