Healthcare Provider Details

I. General information

NPI: 1477534709
Provider Name (Legal Business Name): STREET DRUG CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 08/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 W MAIN ST
LEBANON VA
24266-4214
US

IV. Provider business mailing address

110 W MAIN ST
LEBANON VA
24266-4214
US

V. Phone/Fax

Practice location:
  • Phone: 276-889-1919
  • Fax: 276-889-4635
Mailing address:
  • Phone: 276-889-1919
  • Fax: 276-889-4635

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 Number0201002833
License Number StateVA

VIII. Authorized Official

Name: RALPH STREET
Title or Position: VP PHARMACY
Credential: RPH
Phone: 276-889-1919