Provider Demographics
NPI:1619222767
Name:BON SECOURS-VIRGINIA HEALTHSOURCE INC
Entity Type:Organization
Organization Name:BON SECOURS-VIRGINIA HEALTHSOURCE INC
Other - Org Name:BON SECOURS GOOD HEALTH PHARMACY AT REYNOLDS CROSSING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF CORP RESPONSIBILITY
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:ODELL
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-281-0271
Mailing Address - Street 1:6900 FOREST AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-1729
Mailing Address - Country:US
Mailing Address - Phone:804-893-8630
Mailing Address - Fax:804-285-1296
Practice Address - Street 1:6900 FOREST AVE STE 100
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230
Practice Address - Country:US
Practice Address - Phone:804-893-8630
Practice Address - Fax:804-285-1296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-16
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010044693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2135975OtherPK