1063685535 NPI number — VIRGINIA VETERANS CARE CENTER PHARMACY

Table of content: (NPI 1063685535)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063685535 NPI number — VIRGINIA VETERANS CARE CENTER PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIRGINIA VETERANS CARE CENTER PHARMACY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
VIRGINIA VETERANS CARE CENTER PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063685535
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4550 SHENANDOAH AVE NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24017-4749
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-982-2860
Provider Business Mailing Address Fax Number:
540-345-5701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4550 SHENANDOAH AVE NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24017-4749
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-982-2860
Provider Business Practice Location Address Fax Number:
540-345-5701
Provider Enumeration Date:
04/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
VANTHIEL
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
540-982-2860

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 0201003706 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 008506973 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2105086 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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