Provider Demographics
NPI:1649203746
Name:GOOCHLAND PHARMACY INC.
Entity Type:Organization
Organization Name:GOOCHLAND PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:II
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:804-556-3607
Mailing Address - Street 1:P.O. BOX 166
Mailing Address - Street 2:
Mailing Address - City:GOOCHLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23063
Mailing Address - Country:US
Mailing Address - Phone:804-556-3607
Mailing Address - Fax:804-556-2414
Practice Address - Street 1:1956 SANDY HOOK RD.
Practice Address - Street 2:
Practice Address - City:GOOCHLAND
Practice Address - State:VA
Practice Address - Zip Code:23063
Practice Address - Country:US
Practice Address - Phone:804-556-3607
Practice Address - Fax:804-556-2414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010024773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8512388Medicaid
VA8512388Medicaid
VA1005070001Medicare NSC