Provider Demographics
NPI:1083745509
Name:CENTRAL VIRGINIA PHARMACY CONSULTANTS, P.C.
Entity Type:Organization
Organization Name:CENTRAL VIRGINIA PHARMACY CONSULTANTS, P.C.
Other - Org Name:TIMBERLAKE HEALTH AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JODI
Authorized Official - Middle Name:V
Authorized Official - Last Name:ETTARE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:434-237-6337
Mailing Address - Street 1:22776 TIMBERLAKE RD APT D
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-7310
Mailing Address - Country:US
Mailing Address - Phone:434-237-6337
Mailing Address - Fax:434-237-6338
Practice Address - Street 1:22776 TIMBERLAKE RD APT D
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-7310
Practice Address - Country:US
Practice Address - Phone:434-237-6337
Practice Address - Fax:434-237-6338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
VA0201004144333600000X, 3336L0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00F10HOtherEFT PROVIDER NO.
VA00119FMedicare PIN
VA5917460001Medicare NSC