1548796600 NPI number — FISHBURNE PHARMACY LLC

Table of content: (NPI 1548796600)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548796600 NPI number — FISHBURNE PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FISHBURNE PHARMACY 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:
FISHBURNE PHARMACY, LLC
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:
1548796600
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
436 S LINDEN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAYNESBORO
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22980-3564
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-949-8211
Provider Business Mailing Address Fax Number:
540-949-4833

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
436 S LINDEN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAYNESBORO
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22980-3564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-949-8211
Provider Business Practice Location Address Fax Number:
540-949-4833
Provider Enumeration Date:
05/11/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GARBER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PHARMACIST
Authorized Official Telephone Number:
540-949-8211

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 0201002091 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2171627 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 008500231 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".