Healthcare Provider Details

I. General information

NPI: 1922187608
Provider Name (Legal Business Name): CENTERVILLE CARDINAL DRUG CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 09/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46A BROAD STREET RD
MANAKIN SABOT VA
23103-2213
US

IV. Provider business mailing address

46A BROAD STREET RD
MANAKIN SABOT VA
23103-2213
US

V. Phone/Fax

Practice location:
  • Phone: 804-784-5975
  • Fax: 804-784-4118
Mailing address:
  • Phone: 804-784-5975
  • Fax: 804-784-4118

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 Number0201002321
License Number StateVA

VIII. Authorized Official

Name: EARL GUNN
Title or Position: PRES PHCST
Credential:
Phone: 804-784-5975