1447500400 NPI number — GUARDIAN PHARMACY OF VIRGINIA LLC

Table of content: (NPI 1447500400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447500400 NPI number — GUARDIAN PHARMACY OF VIRGINIA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUARDIAN PHARMACY OF VIRGINIA LLC
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:
SOUTHERN PHARMACY SERVICES
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:
1447500400
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
GUARDIAN PHARMACY OF VIRGINIA DEPT 2428
Provider Second Line Business Mailing Address:
P.O. BOX 11407
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35246-2428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-810-0089
Provider Business Mailing Address Fax Number:
404-810-0094

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
860 STAFFORD UMBERGER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WYTHEVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24382
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-228-5940
Provider Business Practice Location Address Fax Number:
866-928-3983
Provider Enumeration Date:
09/17/2012

Additional Information

Authorized Official

Authorized Official Last Name:
TERRY
Authorized Official First Name:
CHAD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
866-768-8479

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X , with the licence number:  201003165 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X , with the licence number: MO0559211 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 11375 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 3903 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1447500400 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810024876 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4844266 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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