Provider Demographics
NPI:1255395968
Name:MARYVIEW OUTPATIENT PHARMACY
Entity type:Organization
Organization Name:MARYVIEW OUTPATIENT PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MRS
Authorized Official - First Name:KLISTA
Authorized Official - Middle Name:C
Authorized Official - Last Name:NAJEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:757-398-2245
Mailing Address - Street 1:3636 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-3236
Mailing Address - Country:US
Mailing Address - Phone:757-398-2245
Mailing Address - Fax:757-393-7511
Practice Address - Street 1:3636 HIGH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3236
Practice Address - Country:US
Practice Address - Phone:757-398-2245
Practice Address - Fax:757-393-7511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-12
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201003256333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008572011Medicaid