Provider Demographics
NPI:1063685535
Name:VIRGINIA VETERANS CARE CENTER PHARMACY
Entity Type:Organization
Organization Name:VIRGINIA VETERANS CARE CENTER PHARMACY
Other - Org Name:VIRGINIA VETERANS CARE CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:VANTHIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-982-2860
Mailing Address - Street 1:4550 SHENANDOAH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24017-4749
Mailing Address - Country:US
Mailing Address - Phone:540-982-2860
Mailing Address - Fax:540-345-5701
Practice Address - Street 1:4550 SHENANDOAH AVE NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24017-4749
Practice Address - Country:US
Practice Address - Phone:540-982-2860
Practice Address - Fax:540-345-5701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010037063336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008506973Medicaid
2105086OtherPK