Healthcare Provider Details

I. General information

NPI: 1417970880
Provider Name (Legal Business Name): FORK UNION PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 10/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4316 B JAMES MADISON HWY
FORK UNION VA
23055
US

IV. Provider business mailing address

PO BOX 187
FORK UNION VA
23055-0187
US

V. Phone/Fax

Practice location:
  • Phone: 434-842-3208
  • Fax: 434-842-1447
Mailing address:
  • Phone: 434-842-3288
  • Fax: 434-842-1447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0201000280
License Number StateVA

VIII. Authorized Official

Name: IVAN YONCE
Title or Position: OWNER AND PHARMACIST
Credential:
Phone: 434-842-3208