Healthcare Provider Details

I. General information

NPI: 1710981618
Provider Name (Legal Business Name): BURNT CHIMNEY PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2152 DALE AVE SE
ROANOKE VA
24013-2136
US

IV. Provider business mailing address

2152 DALE AVE SE
ROANOKE VA
24013-2136
US

V. Phone/Fax

Practice location:
  • Phone: 540-345-8342
  • Fax: 540-345-8237
Mailing address:
  • Phone: 540-345-8342
  • Fax: 540-345-8237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number0230003079
License Number StateVA

VIII. Authorized Official

Name: EMILY HETHERINGTON
Title or Position: CERTIFIED PHARMACY TECHNICIAN
Credential: CPHT
Phone: 540-345-8342