Provider Demographics
NPI:1669409801
Name:PRINCE GEORGE PHARMACY INC
Entity type:Organization
Organization Name:PRINCE GEORGE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-861-3400
Mailing Address - Street 1:5720 COURTHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:PRINCE GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23875-3215
Mailing Address - Country:US
Mailing Address - Phone:804-861-3400
Mailing Address - Fax:804-861-2617
Practice Address - Street 1:5720 COURTHOUSE RD
Practice Address - Street 2:
Practice Address - City:PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23875-3215
Practice Address - Country:US
Practice Address - Phone:804-861-3400
Practice Address - Fax:804-861-2617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010018723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8513414Medicaid