Healthcare Provider Details

I. General information

NPI: 1053841015
Provider Name (Legal Business Name): SPECIALTY CARE RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 FASHION RD STE ABC
POUNDING MILL VA
24637-1200
US

IV. Provider business mailing address

111 FASHION RD STE ABC
POUNDING MILL VA
24637-1200
US

V. Phone/Fax

Practice location:
  • Phone: 276-345-0284
  • Fax: 276-345-0284
Mailing address:
  • Phone: 276-345-0284
  • Fax: 276-345-9356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number0201004783
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number0201004783
License Number StateVA

VIII. Authorized Official

Name: WESLEY V.A. WATERS III
Title or Position: MANAGER
Credential:
Phone: 406-531-5888