Healthcare Provider Details

I. General information

NPI: 1619935145
Provider Name (Legal Business Name): PROVIDENCE VAMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 CHALKSTONE AVE
PROVIDENCE RI
02908-4734
US

IV. Provider business mailing address

PO BOX 94448
CLEVELAND OH
44101-4448
US

V. Phone/Fax

Practice location:
  • Phone: 401-273-7100
  • Fax: 401-457-1421
Mailing address:
  • Phone: 717-277-6565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332100000X
TaxonomyDepartment of Veterans Affairs (VA) Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ERIN DENISE POTTER
Title or Position: NPI TEAM
Credential:
Phone: 202-382-2579