Provider Demographics
NPI:1689763773
Name:WILLIAMSBURG PHARMACY, INC.
Entity Type:Organization
Organization Name:WILLIAMSBURG PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:R
Authorized Official - Last Name:CONZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:413-268-3387
Mailing Address - Street 1:PO BOX 397
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01096-0397
Mailing Address - Country:US
Mailing Address - Phone:413-268-3387
Mailing Address - Fax:
Practice Address - Street 1:49 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:MA
Practice Address - Zip Code:01096
Practice Address - Country:US
Practice Address - Phone:413-268-3387
Practice Address - Fax:413-268-7391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA25093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0434442Medicaid