Provider Demographics
NPI:1417970880
Name:FORK UNION PHARMACY INC
Entity Type:Organization
Organization Name:FORK UNION PHARMACY INC
Other - Org Name:FORK UNION PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:YONCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-842-3208
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:FORK UNION
Mailing Address - State:VA
Mailing Address - Zip Code:23055-0187
Mailing Address - Country:US
Mailing Address - Phone:434-842-3288
Mailing Address - Fax:434-842-1447
Practice Address - Street 1:4316 B JAMES MADISON HWY
Practice Address - Street 2:
Practice Address - City:FORK UNION
Practice Address - State:VA
Practice Address - Zip Code:23055
Practice Address - Country:US
Practice Address - Phone:434-842-3208
Practice Address - Fax:434-842-1447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010002803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8505357Medicaid
VA1417970880Medicaid
2102630OtherPK
VA1417970880Medicaid