MEDICARE: OLD DOMINION PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	0201004590	VA

General Provider Information

NPI Number	:	1346777000
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLD DOMINION PHARMACY LLC

Provider Business Mailing Address
First Line	:	8792 SACRAMENTO DR
Second Line	:	SUITE I
City	:	ALEXANDRIA
State	:	VA
Zip	:	22309-1676
Country	:	US
Telephone Number	:	800-718-6003
Fax Number	:

Provider Business Practice Location Address
First Line	:	8792 SACRAMENTO DR
Second Line	:	SUITE I
City	:	ALEXANDRIA
State	:	VA
Zip	:	22309-1676
Country	:	US
Telephone Number	:	800-718-6003
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMEBR
Name	:	PAUL MICHAEL RAKOWSKI
Credential	:
Telephone Number	:	800-718-6003

Provider Enumeration Date	:	05/12/2017
Last Update Date	:	05/12/2017

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Directions to “OLD DOMINION PHARMACY LLC ” Practice Location

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