MEDICARE: POWHATAN RX LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	0201004821	VA

General Provider Information

NPI Number	:	1568976272
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POWHATAN RX LLC

Provider Business Mailing Address
First Line	:	2105 ACADEMY RD
Second Line	:
City	:	POWHATAN
State	:	VA
Zip	:	23139-5829
Country	:	US
Telephone Number	:	804-376-7168
Fax Number	:	804-376-7982

Provider Business Practice Location Address
First Line	:	2105 ACADEMY RD
Second Line	:
City	:	POWHATAN
State	:	VA
Zip	:	23139-5829
Country	:	US
Telephone Number	:	804-376-7168
Fax Number	:	804-376-7982

Authorized Official
Title or Position	:	OWNER/PHARMACIST
Name	:	MRS. ELIZABETH WILEY GOODWYN
Credential	:	RPH
Telephone Number	:	804-376-7168

Provider Enumeration Date	:	11/17/2017
Last Update Date	:	07/24/2024

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