1639148521 NPI number — SHAWSVILLE PHARMACY INC

Table of content: (NPI 1639148521)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639148521 NPI number — SHAWSVILLE PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHAWSVILLE PHARMACY 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:
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:
1639148521
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 308
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHAWSVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24162-0308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6920 ROANOKE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHAWSVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-268-2555
Provider Business Practice Location Address Fax Number:
540-268-5009
Provider Enumeration Date:
03/14/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FAUBER
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST CO OWNER
Authorized Official Telephone Number:
540-268-2555

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: 0201002356 , 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: 008515671 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009132341 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4820470 . This is a "NCPDP" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1770910655 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4844949 . This is a "NCPDP" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".