Provider Demographics
NPI:1396701587
Name:CUNDIFF DRUG STORE INC
Entity type:Organization
Organization Name:CUNDIFF DRUG STORE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CUNDIFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-342-8928
Mailing Address - Street 1:119 E CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:VA
Mailing Address - Zip Code:24179-2538
Mailing Address - Country:US
Mailing Address - Phone:540-342-8928
Mailing Address - Fax:540-343-8214
Practice Address - Street 1:119 E CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:VA
Practice Address - Zip Code:24179-2538
Practice Address - Country:US
Practice Address - Phone:540-342-8928
Practice Address - Fax:540-343-8214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010001413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2102209OtherPK
VA8506469Medicaid
0284490001Medicare NSC