Provider Demographics
NPI:1952306052
Name:POWHATAN PHARMACY INC
Entity Type:Organization
Organization Name:POWHATAN PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-379-6986
Mailing Address - Street 1:1799 SOUTHCREEK ONE
Mailing Address - Street 2:STE L
Mailing Address - City:POWHATAN
Mailing Address - State:VA
Mailing Address - Zip Code:23139-7960
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1799 SOUTHCREEK ONE
Practice Address - Street 2:STE A
Practice Address - City:POWHATAN
Practice Address - State:VA
Practice Address - Zip Code:23139-7960
Practice Address - Country:US
Practice Address - Phone:804-379-6986
Practice Address - Fax:804-379-1086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201001368332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4808361OtherNABP
VA00022FOtherMEDICARE FLU
VA009138854Medicaid
VA008510644Medicaid
VAP00231424OtherMEDICARE RAILROAD
VA008510644Medicaid