Provider Demographics
NPI:1093800914
Name:JEFF DALTON INC MEDICINE SHOPPE
Entity Type:Organization
Organization Name:JEFF DALTON INC MEDICINE SHOPPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:DALTON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:434-369-5257
Mailing Address - Street 1:1230 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALTAVISTA
Mailing Address - State:VA
Mailing Address - Zip Code:24517-1466
Mailing Address - Country:US
Mailing Address - Phone:434-369-5257
Mailing Address - Fax:434-369-1061
Practice Address - Street 1:1230 MAIN ST
Practice Address - Street 2:
Practice Address - City:ALTAVISTA
Practice Address - State:VA
Practice Address - Zip Code:24517-1466
Practice Address - Country:US
Practice Address - Phone:434-369-5257
Practice Address - Fax:434-369-1061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201003405333600000X
VA3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008517371Medicaid
VA010332591Medicaid
VABM5362873OtherDEA #
VA008517371Medicaid