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General NPI Number Information
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NPI Number | 1447670849
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Entity Type | Organization
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Legal Business Name | BLUE RIDGE APOTHECARY INC
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Dates
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Enumeration Date | 04/24/2014
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Last Update Date | 02/22/2017
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Provider Practice Location Address
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Address Line | 2122 COLONIAL AVE SW
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City | ROANOKE
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State | VA
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Zip | 24015-3205
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Country | US
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Telephone | 540-345-6480
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Fax | 540-345-6844
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Provider Business Mailing Address
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Address Line | 2122 COLONIAL AVE SW
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City | ROANOKE
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State | VA
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Zip | 24015-3205
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Country | US
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Telephone | 540-345-6480
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Fax | 540-345-6844
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Authorized Official
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Title or Position | OWNER/CEO
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Name | GRAHAM STEPHENS
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Credential |
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Telephone | 540-345-6480
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number | 020100003731
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License Number State | VA
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