1841286580 NPI number — TIMBERVILLE DRUG STORE INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841286580 NPI number — TIMBERVILLE DRUG STORE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIMBERVILLE DRUG STORE 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:
1841286580
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 358
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TIMBERVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22853-0358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-896-3171
Provider Business Mailing Address Fax Number:
540-896-3145

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 S MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TIMBERVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22853
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-896-3171
Provider Business Practice Location Address Fax Number:
540-896-3145
Provider Enumeration Date:
09/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GARBER
Authorized Official First Name:
JOHNNY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
540-896-3171

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: 0201000826 , 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: 4817118 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 008503311 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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