Provider Demographics
NPI:1083711824
Name:STUARTS DRAFT FAMILY PHARMACY INC
Entity Type:Organization
Organization Name:STUARTS DRAFT FAMILY PHARMACY INC
Other - Org Name:STUARTS DRAFT FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARTY
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHREYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-337-3776
Mailing Address - Street 1:PO BOX 791
Mailing Address - Street 2:
Mailing Address - City:STUARTS DRAFT
Mailing Address - State:VA
Mailing Address - Zip Code:24477-0791
Mailing Address - Country:US
Mailing Address - Phone:540-337-3776
Mailing Address - Fax:540-337-9321
Practice Address - Street 1:2929 STUARTS DRAFT HWY
Practice Address - Street 2:STE 101
Practice Address - City:STUARTS DRAFT
Practice Address - State:VA
Practice Address - Zip Code:24477-2753
Practice Address - Country:US
Practice Address - Phone:540-337-3776
Practice Address - Fax:540-337-9321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010034803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2107303OtherPK
VA1083711824Medicaid
2107303OtherPK
VA008505977Medicaid
4832499OtherOTHER ID NUMBER
VA009112839Medicaid