Provider Demographics
NPI:1821021809
Name:BELLEVUE PHARMACY, INC
Entity Type:Organization
Organization Name:BELLEVUE PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LORENZO
Authorized Official - Middle Name:T
Authorized Official - Last Name:MURRAY
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:804-264-0458
Mailing Address - Street 1:PO BOX 653
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114
Mailing Address - Country:US
Mailing Address - Phone:804-264-0458
Mailing Address - Fax:804-264-4588
Practice Address - Street 1:4038 MACARTHUR AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227
Practice Address - Country:US
Practice Address - Phone:804-264-0458
Practice Address - Fax:804-264-4588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010032143336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008509115Medicaid
VA1821021809Medicaid
VA1821021809Medicaid