1629359161 NPI number — SERVANT PHARMACY OF VIRGINIA INC

Table of content: (NPI 1629359161)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629359161 NPI number — SERVANT PHARMACY OF VIRGINIA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERVANT PHARMACY OF VIRGINIA 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:
1629359161
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2451 CUMBERLAND PKWY SE
Provider Second Line Business Mailing Address:
SUITE 3694
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30339-6136
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-303-1680
Provider Business Mailing Address Fax Number:
678-303-1686

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10370 BATTLEVIEW PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANASSAS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20109-2338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-303-1680
Provider Business Practice Location Address Fax Number:
678-303-1686
Provider Enumeration Date:
08/29/2011

Additional Information

Authorized Official

Authorized Official Last Name:
ANGEL
Authorized Official First Name:
RANDY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/COO
Authorized Official Telephone Number:
919-760-5483

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X , with the licence number:  0201004415 , 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: 2131606 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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