MEDICARE: POWHATAN PHARMACY INC

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	332B00000X	Durable Medical Equipment & Medical Supplies	0201001368	VA
2	3336C0003X	Community/Retail Pharmacy	0201001368	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	00022F	OTHER	VA	MEDICARE FLU
5	P00231424	OTHER	VA	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4808361	OTHER	VA	NABP
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952306052
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POWHATAN PHARMACY INC

Provider Business Mailing Address
First Line	:	1799 SOUTHCREEK ONE
Second Line	:	STE L
City	:	POWHATAN
State	:	VA
Zip	:	23139-7960
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1799 SOUTHCREEK ONE
Second Line	:	STE A
City	:	POWHATAN
State	:	VA
Zip	:	23139-7960
Country	:	US
Telephone Number	:	804-379-6986
Fax Number	:	804-379-1086

Authorized Official
Title or Position	:	PHARMACY DIRECTOR
Name	:	GINA THOMPSON
Credential	:
Telephone Number	:	804-379-6986

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	06/01/2015

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Directions to “POWHATAN PHARMACY INC ” Practice Location

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