Provider Demographics
NPI: | 1477089639 |
---|---|
Name: | CHARLOTTESVILLE FREE CLINIC |
Entity Type: | Organization |
Organization Name: | CHARLOTTESVILLE FREE CLINIC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PHARMACY MANAGER |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | LAWRENCE |
Authorized Official - Middle Name: | MELVIN |
Authorized Official - Last Name: | THOMPSON |
Authorized Official - Suffix: | III |
Authorized Official - Credentials: | CPHT |
Authorized Official - Phone: | 434-296-5525 |
Mailing Address - Street 1: | 901 PRESTON AVE, SUITE 101 |
Mailing Address - Street 2: | |
Mailing Address - City: | CHARLOTTESVILLE |
Mailing Address - State: | VA |
Mailing Address - Zip Code: | 22903 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 434-295-8957 |
Mailing Address - Fax: | 434-296-0904 |
Practice Address - Street 1: | 901 PRESTON AVE, SUITE 101 |
Practice Address - Street 2: | |
Practice Address - City: | CHARLOTTESVILLE |
Practice Address - State: | VA |
Practice Address - Zip Code: | 22903 |
Practice Address - Country: | US |
Practice Address - Phone: | 434-295-8957 |
Practice Address - Fax: | 434-296-0904 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-05-10 |
Last Update Date: | 2023-03-24 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
VA | 0201003106 | 333600000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 333600000X | Suppliers | Pharmacy |