Provider Demographics
NPI:1437324035
Name:WILLIAMSBURG PHARMACY
Entity Type:Organization
Organization Name:WILLIAMSBURG PHARMACY
Other - Org Name:MAIDEN DRUG COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:JONATHAN
Authorized Official - Last Name:POWERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-549-0449
Mailing Address - Street 1:327 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40769-1123
Mailing Address - Country:US
Mailing Address - Phone:606-549-0449
Mailing Address - Fax:606-549-3233
Practice Address - Street 1:327 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-1123
Practice Address - Country:US
Practice Address - Phone:606-549-0449
Practice Address - Fax:606-549-3233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP02254332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54025325Medicaid
KY54025325Medicaid