=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487792974
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDEPENDENCE ALIVE & WELL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 02/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 509 N MAIN ST
-----------------------------------------------------
City | BRIDGEWATER
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22812-1626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-828-6000
-----------------------------------------------------
Fax | 540-828-2743
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 509 N MAIN ST
-----------------------------------------------------
City | BRIDGEWATER
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22812-1626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-828-6000
-----------------------------------------------------
Fax | 540-828-2743
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. PATRICK ANDREW OSHEA
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 540-828-6000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 0201003486
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------