Provider Demographics
NPI:1588842959
Name:VALLEY COMPOUNDING PHARMACY, P.C.
Entity Type:Organization
Organization Name:VALLEY COMPOUNDING PHARMACY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:ETTARE
Authorized Official - Suffix:II
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:434-237-3331
Mailing Address - Street 1:2201 LANGHORNE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1124
Mailing Address - Country:US
Mailing Address - Phone:434-237-3331
Mailing Address - Fax:
Practice Address - Street 1:22776 TIMBERLAKE RD
Practice Address - Street 2:SUITE C
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-7310
Practice Address - Country:US
Practice Address - Phone:434-237-3331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010042033336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy