Provider Demographics
NPI:1528016771
Name:KILMARNOCK PHARMACY INC
Entity Type:Organization
Organization Name:KILMARNOCK PHARMACY INC
Other - Org Name:MAIN STREET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLL
Authorized Official - Middle Name:
Authorized Official - Last Name:THROCKMORTON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:804-435-8818
Mailing Address - Street 1:308 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KILMARNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22482-3834
Mailing Address - Country:US
Mailing Address - Phone:804-435-8818
Mailing Address - Fax:804-435-8898
Practice Address - Street 1:308 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KILMARNOCK
Practice Address - State:VA
Practice Address - Zip Code:22482-3834
Practice Address - Country:US
Practice Address - Phone:804-435-8818
Practice Address - Fax:804-435-8898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010040773336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010265975Medicaid
4839227OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5667080001Medicare NSC