=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356374268
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARTINSVILLE FAMILY PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2006
-----------------------------------------------------
Last Update Date | 09/13/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1049A BROOKDALE ST
-----------------------------------------------------
City | MARTINSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24112-3950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-634-0922
-----------------------------------------------------
Fax | 276-634-5048
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4589
-----------------------------------------------------
City | MARTINSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24115-4589
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ROBERT PRATT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 276-634-0922
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 0201003742
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------