Provider Demographics
NPI:1598733768
Name:COMMUNITY RESOURCE PHARMACY
Entity Type:Organization
Organization Name:COMMUNITY RESOURCE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:804-524-7657
Mailing Address - Street 1:PO BOX 4030
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-0030
Mailing Address - Country:US
Mailing Address - Phone:804-524-7657
Mailing Address - Fax:804-524-7079
Practice Address - Street 1:26317 WEST WASHINGTON STREET,
Practice Address - Street 2:EXTENDED BUILDING #110
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803
Practice Address - Country:US
Practice Address - Phone:804-524-7657
Practice Address - Fax:804-524-7079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201004069251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4813297OtherNABP NUMBER