Provider Demographics
NPI:1780699389
Name:MEDICAL PLAZA PHARMACY
Entity type:Organization
Organization Name:MEDICAL PLAZA PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-596-6600
Mailing Address - Street 1:2951 FRONT ST STE 1850
Mailing Address - Street 2:
Mailing Address - City:RICHLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:24641-2064
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2951 FRONT ST STE 1850
Practice Address - Street 2:
Practice Address - City:RICHLANDS
Practice Address - State:VA
Practice Address - Zip Code:24641-2064
Practice Address - Country:US
Practice Address - Phone:276-596-6600
Practice Address - Fax:276-596-6626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010021053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4818829OtherNCPDP PROVIDER IDENTIFICATION NUMBER
VA0006190003Medicaid
VA8514445Medicaid