Provider Demographics
NPI:1922187608
Name:CENTERVILLE CARDINAL DRUG CENTER INC
Entity Type:Organization
Organization Name:CENTERVILLE CARDINAL DRUG CENTER INC
Other - Org Name:GUNNS PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES PHCST
Authorized Official - Prefix:
Authorized Official - First Name:EARL
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-784-5975
Mailing Address - Street 1:46A BROAD STREET RD
Mailing Address - Street 2:
Mailing Address - City:MANAKIN SABOT
Mailing Address - State:VA
Mailing Address - Zip Code:23103-2213
Mailing Address - Country:US
Mailing Address - Phone:804-784-5975
Mailing Address - Fax:804-784-4118
Practice Address - Street 1:46A BROAD STREET RD
Practice Address - Street 2:
Practice Address - City:MANAKIN SABOT
Practice Address - State:VA
Practice Address - Zip Code:23103-2213
Practice Address - Country:US
Practice Address - Phone:804-784-5975
Practice Address - Fax:804-784-4118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010023213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8515638Medicaid
2104364OtherPK
VA8515638Medicaid