Provider Demographics
NPI:1275511768
Name:HDMC PHARMACY
Entity Type:Organization
Organization Name:HDMC PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FACILITY DIRECTOR/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JARVIS
Authorized Official - Middle Name:T
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:DHA, LNHA, CPHQ
Authorized Official - Phone:804-524-7112
Mailing Address - Street 1:26317 W WASHINGTON STREET EXTENDED
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803
Mailing Address - Country:US
Mailing Address - Phone:804-524-7744
Mailing Address - Fax:804-524-4718
Practice Address - Street 1:26317 W WASHINGTON STREET EXTENDED
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803
Practice Address - Country:US
Practice Address - Phone:804-524-7744
Practice Address - Fax:804-524-4718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-04
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201001240333600000X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA49-0104/495113Medicaid