1508896598 NPI number — APPOMATTOX DRUG STORE INC

Table of content: (NPI 1508896598)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508896598 NPI number — APPOMATTOX DRUG STORE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
APPOMATTOX DRUG STORE INC
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:
APPOMATTOX DRUG STORE
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:
1508896598
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 489
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APPOMATTOX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24522-0489
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-352-7161
Provider Business Mailing Address Fax Number:
434-352-2180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2046 CONFEDERATE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
APPOMATTOX
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24522-4097
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-352-7161
Provider Business Practice Location Address Fax Number:
434-352-2180
Provider Enumeration Date:
07/04/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MITCHELL
Authorized Official First Name:
JAMIE
Authorized Official Middle Name:
Authorized Official Title or Position:
GENERAL MANAGER
Authorized Official Telephone Number:
434-352-7161

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 0201001785 , 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: 008511268 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2102351 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8511268 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".