Provider Demographics
NPI:1689035677
Name:JUSTUS, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:JUSTUS
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 1:28 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-3331
Mailing Address - Country:US
Mailing Address - Phone:304-752-2910
Mailing Address - Fax:304-752-5883
Practice Address - Street 1:2138 S MAYO TRL
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-2296
Practice Address - Country:US
Practice Address - Phone:606-432-2044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-17
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202211472183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist