Provider Demographics
NPI:1093238206
Name:VIRGINIA COMMONWEALTH UNIVERSITY HEALTH SYSTEM AUTHORITY
Entity Type:Organization
Organization Name:VIRGINIA COMMONWEALTH UNIVERSITY HEALTH SYSTEM AUTHORITY
Other - Org Name:VCU HEALTH SYSTEM - SPECIALITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCE AND ACCOUNTING
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-628-1338
Mailing Address - Street 1:PO BOX 758997
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-0001
Mailing Address - Country:US
Mailing Address - Phone:804-628-6643
Mailing Address - Fax:
Practice Address - Street 1:1030 WILMER AVE STE 300
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227-2403
Practice Address - Country:US
Practice Address - Phone:877-814-3475
Practice Address - Fax:804-364-6585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-19
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336S0011X
VA02022114583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30015174800079Medicaid