Healthcare Provider Details

I. General information

NPI: 1831278514
Provider Name (Legal Business Name): LAKE CENTRE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 CENTRE CT
PALMYRA VA
22963-2329
US

IV. Provider business mailing address

4 CENTRE CT
PALMYRA VA
22963-2329
US

V. Phone/Fax

Practice location:
  • Phone: 434-589-6622
  • Fax: 434-589-6623
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0201003083
License Number StateVA

VIII. Authorized Official

Name: ELIJAH OWEN
Title or Position: OWNER
Credential:
Phone: 435-589-6622