1568600989 NPI number — LONESOME PINE ECONOMY DRUG, INC.

Table of content: (NPI 1568600989)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568600989 NPI number — LONESOME PINE ECONOMY DRUG, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LONESOME PINE ECONOMY DRUG, 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:
Provider Other Organization Name Type Code:
6
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:
1568600989
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HURLEY
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-566-4488
Provider Business Mailing Address Fax Number:
276-566-8778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
517 PARK AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24273
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-679-5190
Provider Business Practice Location Address Fax Number:
276-566-8778
Provider Enumeration Date:
01/22/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT/PHARMACIST
Authorized Official Telephone Number:
276-566-4488

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  0201004267 , 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: 0201004267 . This is a "VIRGINIA STATE LICENSE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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