Provider Demographics
NPI:1205204286
Name:BON SECOURS-VIRGINIA HEALTHSOURCE INC
Entity Type:Organization
Organization Name:BON SECOURS-VIRGINIA HEALTHSOURCE INC
Other - Org Name:GOOD HEALTH PHARMACY AT HANOVER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SYSTEM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:RALSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-996-5119
Mailing Address - Street 1:8200 MEADOWBRIDGE RD STE 301
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-2337
Mailing Address - Country:US
Mailing Address - Phone:804-442-3754
Mailing Address - Fax:804-569-6034
Practice Address - Street 1:8200 MEADOWBRIDGE RD STE 301
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116
Practice Address - Country:US
Practice Address - Phone:804-442-3754
Practice Address - Fax:804-569-6034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-09
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010046673336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1205204286Medicaid
2153965OtherPK