Provider Demographics
NPI:1851405849
Name:DOWNHOME PHARMACY P C
Entity Type:Organization
Organization Name:DOWNHOME PHARMACY P C
Other - Org Name:DOWNHOME PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:540-966-4858
Mailing Address - Street 1:671 TERESA LN
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-8453
Mailing Address - Country:US
Mailing Address - Phone:540-966-4858
Mailing Address - Fax:540-992-3273
Practice Address - Street 1:671 TERESA LN
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-8453
Practice Address - Country:US
Practice Address - Phone:540-966-4858
Practice Address - Fax:540-992-3273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
VA02010037653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8512540Medicaid
2105206OtherPK
VA8512540Medicaid
VA9108696Medicaid