Healthcare Provider Details

I. General information

NPI: 1750474938
Provider Name (Legal Business Name): WAVERLY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 01/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 W MAIN ST
WAVERLY VA
23890-3235
US

IV. Provider business mailing address

328 W MAIN ST
WAVERLY VA
23890-3235
US

V. Phone/Fax

Practice location:
  • Phone: 804-220-1489
  • Fax: 804-834-7645
Mailing address:
  • Phone: 804-220-1489
  • Fax: 804-834-7645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0201000860
License Number StateVA

VIII. Authorized Official

Name: DENISE MARIE TIDWELL
Title or Position: PIC/MANAGING MEMBER
Credential: RPH
Phone: 804-368-3834