Provider Demographics
NPI:1588675078
Name:SERVANT PHARMACY OF VIRGINIA INC
Entity Type:Organization
Organization Name:SERVANT PHARMACY OF VIRGINIA INC
Other - Org Name:SERVANT PHARMACY OF VIRGINIA LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHRMD
Authorized Official - Phone:919-760-5483
Mailing Address - Street 1:2451 CUMBERLAND PKWY SE
Mailing Address - Street 2:SUITE 3694
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-6136
Mailing Address - Country:US
Mailing Address - Phone:678-303-1680
Mailing Address - Fax:678-303-1686
Practice Address - Street 1:90 TOWN CENTER ST STE 204
Practice Address - Street 2:
Practice Address - City:DALEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24083-3742
Practice Address - Country:US
Practice Address - Phone:540-777-1505
Practice Address - Fax:540-777-1507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010039723336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4838112OtherNCPDP PROVIDER IDENTIFICATION NUMBER
VA8512655Medicaid