Provider Demographics
NPI:1700891306
Name:COMMUNITY PHCY OF SOUTH BOSTON,INC
Entity Type:Organization
Organization Name:COMMUNITY PHCY OF SOUTH BOSTON,INC
Other - Org Name:COMMUNITY PHCY OF SOUTH BOSTON INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-575-7988
Mailing Address - Street 1:PO BOX 506
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-0506
Mailing Address - Country:US
Mailing Address - Phone:434-575-7988
Mailing Address - Fax:434-575-1358
Practice Address - Street 1:2202 BEECHMONT RD
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1614
Practice Address - Country:US
Practice Address - Phone:434-575-7988
Practice Address - Fax:434-575-1358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010019353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4809628OtherNCPDP PROVIDER IDENTIFICATION NUMBER
VA8508259Medicaid
0142480001Medicare NSC