Healthcare Provider Details

I. General information

NPI: 1780744490
Provider Name (Legal Business Name): SPENCERS DRUG STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MAIN ST
BLACKSTONE VA
23824-1424
US

IV. Provider business mailing address

100 N MAIN ST
BLACKSTONE VA
23824-1424
US

V. Phone/Fax

Practice location:
  • Phone: 434-292-3132
  • Fax: 434-292-6467
Mailing address:
  • Phone: 434-292-3132
  • Fax: 434-292-6467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0201000758
License Number StateVA

VIII. Authorized Official

Name: KERI YANCEY
Title or Position: OWNER
Credential:
Phone: 434-292-3132