Healthcare Provider Details

I. General information

NPI: 1598733768
Provider Name (Legal Business Name): COMMUNITY RESOURCE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26317 WEST WASHINGTON STREET, EXTENDED BUILDING #110
PETERSBURG VA
23803
US

IV. Provider business mailing address

PO BOX 4030
PETERSBURG VA
23803-0030
US

V. Phone/Fax

Practice location:
  • Phone: 804-524-7657
  • Fax: 804-524-7079
Mailing address:
  • Phone: 804-524-7657
  • Fax: 804-524-7079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number0201004069
License Number StateVA

VIII. Authorized Official

Name: MR. JOHN E. WALL
Title or Position: PHARMACIST-IN-CHARGE
Credential: R.PH.
Phone: 804-524-7657