Provider Demographics
NPI:1457582652
Name:CUNDIFF BLUE RIDGE PHARMACY, INC.
Entity Type:Organization
Organization Name:CUNDIFF BLUE RIDGE PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:CLEVELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-977-4224
Mailing Address - Street 1:1663 BLUE RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:TROUTVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24175-6636
Mailing Address - Country:US
Mailing Address - Phone:540-977-4224
Mailing Address - Fax:540-977-0297
Practice Address - Street 1:1663 BLUE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:TROUTVILLE
Practice Address - State:VA
Practice Address - Zip Code:24175-6636
Practice Address - Country:US
Practice Address - Phone:540-977-4224
Practice Address - Fax:540-977-0297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-05
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201002463333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0175200001Medicare NSC