Provider Demographics
NPI:1174620918
Name:OLDE VIRGINIA PHARMACY, INC.
Entity type:Organization
Organization Name:OLDE VIRGINIA PHARMACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:276-988-7977
Mailing Address - Street 1:PO BOX 664
Mailing Address - Street 2:
Mailing Address - City:TAZEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:24651-0664
Mailing Address - Country:US
Mailing Address - Phone:276-988-7977
Mailing Address - Fax:276-988-1098
Practice Address - Street 1:1592 FINCASTLE TPKE
Practice Address - Street 2:
Practice Address - City:TAZEWELL
Practice Address - State:VA
Practice Address - Zip Code:24651-6167
Practice Address - Country:US
Practice Address - Phone:276-988-7977
Practice Address - Fax:276-988-7469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010033183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2106896OtherPK
VA8507473Medicaid
VA8507473Medicaid
1137000001Medicare ID - Type Unspecified