Healthcare Provider Details

I. General information

NPI: 1487792974
Provider Name (Legal Business Name): INDEPENDENCE ALIVE & WELL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 02/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 N MAIN ST
BRIDGEWATER VA
22812-1626
US

IV. Provider business mailing address

509 N MAIN ST
BRIDGEWATER VA
22812-1626
US

V. Phone/Fax

Practice location:
  • Phone: 540-828-6000
  • Fax: 540-828-2743
Mailing address:
  • Phone: 540-828-6000
  • Fax: 540-828-2743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number0201003486
License Number StateVA

VIII. Authorized Official

Name: MR. PATRICK ANDREW OSHEA
Title or Position: OWNER
Credential: RPH
Phone: 540-828-6000