Healthcare Provider Details

I. General information

NPI: 1790226660
Provider Name (Legal Business Name): SMOKEYRUN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2017
Last Update Date: 03/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 CAROLINE ST
FREDERICKSBURG VA
22401-5807
US

IV. Provider business mailing address

901 CAROLINE ST
FREDERICKSBURG VA
22401-5807
US

V. Phone/Fax

Practice location:
  • Phone: 540-373-3411
  • Fax: 540-373-9370
Mailing address:
  • Phone: 540-373-3411
  • Fax: 540-373-9370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number0201002870
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number StateNULL

VIII. Authorized Official

Name: CHRISTOPHER CONDER
Title or Position: OWNER/PHARMACIST
Credential:
Phone: 804-239-5803