Provider Demographics
NPI:1639191638
Name:BURNT CHIMNEY PHARMACY INC.
Entity Type:Organization
Organization Name:BURNT CHIMNEY PHARMACY INC.
Other - Org Name:SUPER-D DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-345-8342
Mailing Address - Street 1:414 9TH ST SE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24013-1506
Mailing Address - Country:US
Mailing Address - Phone:540-345-8342
Mailing Address - Fax:540-345-8237
Practice Address - Street 1:414 9TH ST SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24013-1506
Practice Address - Country:US
Practice Address - Phone:540-345-8342
Practice Address - Fax:540-345-8237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201003224183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8514020Medicaid