Healthcare Provider Details

I. General information

NPI: 1922889807
Provider Name (Legal Business Name): WYTHEVILLE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2023
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 E MAIN ST
WYTHEVILLE VA
24382-3303
US

IV. Provider business mailing address

PO BOX 453
HAYSI VA
24256-0453
US

V. Phone/Fax

Practice location:
  • Phone: 276-200-1200
  • Fax: 833-623-3048
Mailing address:
  • Phone: 276-865-5560
  • Fax: 276-865-5310

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 Number
License Number State

VIII. Authorized Official

Name: MR. ERVIN COUNTS
Title or Position: OWNER
Credential: RPH
Phone: 276-865-5560