Healthcare Provider Details

I. General information

NPI: 1093800914
Provider Name (Legal Business Name): JEFF DALTON INC MEDICINE SHOPPE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 MAIN ST
ALTAVISTA VA
24517-1466
US

IV. Provider business mailing address

1230 MAIN ST
ALTAVISTA VA
24517-1466
US

V. Phone/Fax

Practice location:
  • Phone: 434-369-5257
  • Fax: 434-369-1061
Mailing address:
  • Phone: 434-369-5257
  • Fax: 434-369-1061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number0201003405
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateVA

VIII. Authorized Official

Name: MR. JEFF DALTON
Title or Position: PRESIDENT
Credential: R.P.H
Phone: 434-369-5257