Provider Demographics
NPI:1629359161
Name:SERVANT PHARMACY OF VIRGINIA INC
Entity Type:Organization
Organization Name:SERVANT PHARMACY OF VIRGINIA INC
Other - Org Name:SERVANT PHARMACY OF VIRGINIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/COO
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
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 1:10370 BATTLEVIEW PKWY
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-2338
Practice Address - Country:US
Practice Address - Phone:678-303-1680
Practice Address - Fax:678-303-1686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-29
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010044153336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2131606OtherPK