Provider Demographics
NPI:1053692095
Name:AVERETTE, CHARLES SAMUEL (RPH)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:SAMUEL
Last Name:AVERETTE
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 1:240 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:VA
Mailing Address - Zip Code:24084-3203
Mailing Address - Country:US
Mailing Address - Phone:540-674-5261
Mailing Address - Fax:540-674-5154
Practice Address - Street 1:240 BROAD ST
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:VA
Practice Address - Zip Code:24084-3203
Practice Address - Country:US
Practice Address - Phone:540-674-5261
Practice Address - Fax:540-674-5154
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-05
Last Update Date:2011-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202004444183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1205071735Medicaid