Provider Demographics
NPI:1922082718
Name:VALLEY REGIONAL ENTERPRISES, INC.
Entity Type:Organization
Organization Name:VALLEY REGIONAL ENTERPRISES, INC.
Other - Org Name:VALLEY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VALLEY REGIONAL ENTERPRISES, INC. P
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:RUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-536-4882
Mailing Address - Street 1:220 CAMPUS BLVD
Mailing Address - Street 2:SUITE 420
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601
Mailing Address - Country:US
Mailing Address - Phone:540-536-4883
Mailing Address - Fax:540-536-8019
Practice Address - Street 1:190 CAMPUS BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601
Practice Address - Country:US
Practice Address - Phone:540-536-8899
Practice Address - Fax:540-536-6424
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VALLEY REGIONAL ENTERPRISES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-05
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201002614333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8517568Medicaid
VA0250670002Medicare NSC