Healthcare Provider Details

I. General information

NPI: 1174620918
Provider Name (Legal Business Name): OLDE VIRGINIA PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 11/02/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1592 FINCASTLE TPKE
TAZEWELL VA
24651-6167
US

IV. Provider business mailing address

PO BOX 664
TAZEWELL VA
24651-0664
US

V. Phone/Fax

Practice location:
  • Phone: 276-988-7977
  • Fax: 276-988-7469
Mailing address:
  • Phone: 276-988-7977
  • Fax: 276-988-1098

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 Number0201003318
License Number StateVA

VIII. Authorized Official

Name: SCOTT COLE
Title or Position: PHARMACIST/OWNER/PRESIDENT
Credential: PHARMD
Phone: 276-988-7977