Provider Demographics
NPI:1841397684
Name:BERRYVILLE PHARMACY
Entity Type:Organization
Organization Name:BERRYVILLE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:VINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-955-3095
Mailing Address - Street 1:8 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BERRYVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22611-1341
Mailing Address - Country:US
Mailing Address - Phone:540-955-1058
Mailing Address - Fax:540-955-3365
Practice Address - Street 1:8 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:VA
Practice Address - Zip Code:22611-1341
Practice Address - Country:US
Practice Address - Phone:540-955-2063
Practice Address - Fax:540-955-3365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201001553333600000X
3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4804921OtherOTHER ID NUMBER-COMMERCIAL NUMBER
VA8505071Medicaid
VA8505071Medicaid