Provider Demographics
NPI:1679622948
Name:APPOMATTOX DRUG STORE
Entity Type:Organization
Organization Name:APPOMATTOX DRUG STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-352-7161
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:APPOMATTOX
Mailing Address - State:VA
Mailing Address - Zip Code:24522-0489
Mailing Address - Country:US
Mailing Address - Phone:434-352-7161
Mailing Address - Fax:434-352-9466
Practice Address - Street 1:2046 CONFEDERATE BLVD
Practice Address - Street 2:
Practice Address - City:APPOMATTOX
Practice Address - State:VA
Practice Address - Zip Code:24522-4097
Practice Address - Country:US
Practice Address - Phone:434-352-7161
Practice Address - Fax:434-352-9466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009106545Medicaid
VA009106545Medicaid