Provider Demographics
NPI:1841738895
Name:MARTINSVILLE PHARMACY INC
Entity Type:Organization
Organization Name:MARTINSVILLE PHARMACY INC
Other - Org Name:MARTINSVILLE PHARMACY INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:BS RPH
Authorized Official - Phone:276-632-0816
Mailing Address - Street 1:1049 BROOKDALE ST STE A
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-3972
Mailing Address - Country:US
Mailing Address - Phone:276-632-0816
Mailing Address - Fax:276-632-0871
Practice Address - Street 1:1049 BROOKDALE ST STE A
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-3972
Practice Address - Country:US
Practice Address - Phone:276-632-0816
Practice Address - Fax:276-632-0871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-09
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
VA02010047623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2168034OtherPK
VA1841738895Medicaid