Healthcare Provider Details

I. General information

NPI: 1447290499
Provider Name (Legal Business Name): DINWIDDIE DRUG STORE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13723 BOYDTON PLANK RD
DINWIDDIE VA
23841-0215
US

IV. Provider business mailing address

PO BOX 215
DINWIDDIE VA
23841-0215
US

V. Phone/Fax

Practice location:
  • Phone: 804-469-3261
  • Fax: 804-469-4623
Mailing address:
  • Phone: 804-469-3261
  • Fax: 804-469-4623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0201003019
License Number StateVA

VIII. Authorized Official

Name: MR. CHARLES A. RAINEY JR.
Title or Position: OWNER
Credential:
Phone: 804-469-3261