Provider Demographics
NPI:1891894754
Name:HOMETOWN PHARMACY LLC
Entity Type:Organization
Organization Name:HOMETOWN PHARMACY LLC
Other - Org Name:HOMETOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-352-3784
Mailing Address - Street 1:PO BOX 2408
Mailing Address - Street 2:
Mailing Address - City:APPOMATTOX
Mailing Address - State:VA
Mailing Address - Zip Code:24522-2408
Mailing Address - Country:US
Mailing Address - Phone:434-352-3784
Mailing Address - Fax:
Practice Address - Street 1:199 OLD COURTHOUSE RD
Practice Address - Street 2:
Practice Address - City:APPOMATTOX
Practice Address - State:VA
Practice Address - Zip Code:24522-9853
Practice Address - Country:US
Practice Address - Phone:434-352-3784
Practice Address - Fax:434-352-3717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010039703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010128323Medicaid
2105476OtherPK
VA010057795Medicaid
5109230001Medicare NSC
VA010057795Medicaid