Provider Demographics
NPI:1073676698
Name:SUBURBAN PHARMACY INC
Entity Type:Organization
Organization Name:SUBURBAN PHARMACY INC
Other - Org Name:SUBURBAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUNIL
Authorized Official - Middle Name:
Authorized Official - Last Name:KANDREGULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-397-2377
Mailing Address - Street 1:3701 KING ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-3115
Mailing Address - Country:US
Mailing Address - Phone:757-397-2377
Mailing Address - Fax:757-399-2013
Practice Address - Street 1:3701 KING ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3115
Practice Address - Country:US
Practice Address - Phone:757-397-2377
Practice Address - Fax:757-399-2013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010024903336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149751OtherPK
4821383OtherNCPDP PROVIDER IDENTIFICATION NUMBER