Provider Demographics
NPI:1669579405
Name:MEADOWBROOK HEALTH SERVICE INC
Entity type:Organization
Organization Name:MEADOWBROOK HEALTH SERVICE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RPH/TREASUER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-718-5423
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:VA
Mailing Address - Zip Code:22727-0160
Mailing Address - Country:US
Mailing Address - Phone:434-296-4135
Mailing Address - Fax:434-220-0438
Practice Address - Street 1:2037 BARRACKS RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-1206
Practice Address - Country:US
Practice Address - Phone:434-296-4135
Practice Address - Fax:434-220-0438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
VA02010020133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8514747Medicaid
2102420OtherPK
2102420OtherPK