Provider Demographics
NPI:1023114584
Name:ABINGDON APOTHECARY, INC.
Entity type:Organization
Organization Name:ABINGDON APOTHECARY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER/PIC
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:RUDOLPH
Authorized Official - Last Name:PETROSKY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:276-628-2001
Mailing Address - Street 1:611 CAMPUS DR.
Mailing Address - Street 2:SUITE 500
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210
Mailing Address - Country:US
Mailing Address - Phone:276-628-2001
Mailing Address - Fax:276-628-2514
Practice Address - Street 1:611 CAMPUS DR.
Practice Address - Street 2:SUITE 500
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210
Practice Address - Country:US
Practice Address - Phone:276-628-2001
Practice Address - Fax:276-628-2514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201002592183500000X, 3336C0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes333600000XSuppliersPharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4823349OtherNCPDP
VA008504067Medicaid
VA008504067Medicaid