Provider Demographics
NPI:1184714230
Name:RUSSELL FORK PHARMACIES, INC.
Entity type:Organization
Organization Name:RUSSELL FORK PHARMACIES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:COUNTS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:276-865-5560
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:HAYSI
Mailing Address - State:VA
Mailing Address - Zip Code:24256-0099
Mailing Address - Country:US
Mailing Address - Phone:276-865-5560
Mailing Address - Fax:276-865-5310
Practice Address - Street 1:164 HAYSI MAIN STREET
Practice Address - Street 2:
Practice Address - City:HAYSI
Practice Address - State:VA
Practice Address - Zip Code:24256
Practice Address - Country:US
Practice Address - Phone:276-865-5560
Practice Address - Fax:276-865-5310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010039113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4837463OtherNCPDP
VA008520020Medicaid
VA008520020Medicaid