Provider Demographics
NPI:1184645145
Name:MEDICAL ARTS PHCY OF ST MARYS
Entity Type:Organization
Organization Name:MEDICAL ARTS PHCY OF ST MARYS
Other - Org Name:MEDICAL ARTS PHCY OF ST MARYS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:276-679-7406
Mailing Address - Street 1:280 VIRGINIA AVE NE STE 105
Mailing Address - Street 2:
Mailing Address - City:NORTON
Mailing Address - State:VA
Mailing Address - Zip Code:24273-1539
Mailing Address - Country:US
Mailing Address - Phone:276-679-7406
Mailing Address - Fax:276-679-7406
Practice Address - Street 1:280 VIRGINIA AVE NE STE 105
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1539
Practice Address - Country:US
Practice Address - Phone:276-679-7406
Practice Address - Fax:276-679-7406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010024883336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008501092Medicaid
4827501OtherNCPDP PROVIDER IDENTIFICATION NUMBER