Provider Demographics
NPI:1942267497
Name:MODERN PHARMACY INC
Entity Type:Organization
Organization Name:MODERN PHARMACY INC
Other - Org Name:MODERN PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:MILAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:434-793-5711
Mailing Address - Street 1:155 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-2921
Mailing Address - Country:US
Mailing Address - Phone:434-793-5711
Mailing Address - Fax:434-792-2516
Practice Address - Street 1:155 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-2921
Practice Address - Country:US
Practice Address - Phone:434-793-5711
Practice Address - Fax:434-792-2516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010004913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2102444OtherPK
VA8502609Medicaid
NC0925669Medicaid
NC0925669Medicaid