Provider Demographics
NPI:1609409010
Name:BUFORD ROAD PHARMACY
Entity Type:Organization
Organization Name:BUFORD ROAD PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CPHT
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:LUCINDA
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-272-1423
Mailing Address - Street 1:2608 BUFORD RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-3422
Mailing Address - Country:US
Mailing Address - Phone:804-272-1423
Mailing Address - Fax:804-272-7967
Practice Address - Street 1:2608 BUFORD RD
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-3422
Practice Address - Country:US
Practice Address - Phone:804-272-1423
Practice Address - Fax:804-272-7967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8507805Medicaid