Provider Demographics
NPI:1629414867
Name:MARY IMMACULATE HOSPITAL
Entity Type:Organization
Organization Name:MARY IMMACULATE HOSPITAL
Other - Org Name:GOOD HEALTH PHARMACY AT MARY IMMACULATE HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:RYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:757-947-3741
Mailing Address - Street 1:12720 MCMANUS BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-4414
Mailing Address - Country:US
Mailing Address - Phone:757-947-3740
Mailing Address - Fax:757-947-3745
Practice Address - Street 1:12720 MCMANUS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4414
Practice Address - Country:US
Practice Address - Phone:757-947-3740
Practice Address - Fax:757-947-3745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-15
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010045173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140328OtherPK
VA1629414867Medicaid