Provider Demographics
NPI:1205255312
Name:BLACKSBURG PHARMACY INC
Entity type:Organization
Organization Name:BLACKSBURG PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SENTHIL
Authorized Official - Middle Name:
Authorized Official - Last Name:MARIMUTHU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-320-3345
Mailing Address - Street 1:1445 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-2563
Mailing Address - Country:US
Mailing Address - Phone:540-552-3000
Mailing Address - Fax:540-552-3005
Practice Address - Street 1:1445 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-2563
Practice Address - Country:US
Practice Address - Phone:540-552-3000
Practice Address - Fax:540-552-3005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-16
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
VA02010045683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1205255312Medicaid
2145266OtherPK
VA1205255312Medicaid