Provider Demographics
NPI:1063460137
Name:CHARLESTON VA CMOP
Entity Type:Organization
Organization Name:CHARLESTON VA CMOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPUTY CHIEF CONSULTANT PBM/CMOP
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SIEHR
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, MPA
Authorized Official - Phone:913-758-4750
Mailing Address - Street 1:3725 RIVERS AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-7038
Mailing Address - Country:US
Mailing Address - Phone:843-745-8631
Mailing Address - Fax:843-747-6841
Practice Address - Street 1:3725 RIVERS AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-7038
Practice Address - Country:US
Practice Address - Phone:843-745-8631
Practice Address - Fax:843-747-6841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332100000XSuppliersDepartment of Veterans Affairs (VA) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4226153OtherNCPDP#
SC4226153OtherDEA#