=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750007860
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARNESS HEALTH PHARMACY - VIRGINIA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2022
-----------------------------------------------------
Last Update Date | 08/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13710 ST FRANCIS BLVD
-----------------------------------------------------
City | MIDLOTHIAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23114-3267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-545-1851
-----------------------------------------------------
Fax | 804-545-1852
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 631868
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45263-1868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-594-2051
-----------------------------------------------------
Fax | 804-594-2050
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT REIMBURSEMENT
-----------------------------------------------------
Name | KIMBERLY M RALSTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 419-996-5119
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------