MEDICARE: BEAVERDAM APOTHECARY

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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	0201001471	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2156211	OTHER	PK
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356417463
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEAVERDAM APOTHECARY

Provider Business Mailing Address
First Line	:	16151 TRAINHAM RD
Second Line	:	STE B
City	:	BEAVERDAM
State	:	VA
Zip	:	23015-1301
Country	:	US
Telephone Number	:	804-449-6333
Fax Number	:	804-449-6173

Provider Business Practice Location Address
First Line	:	16151 TRAINHAM RD
Second Line	:	STE B
City	:	BEAVERDAM
State	:	VA
Zip	:	23015-1301
Country	:	US
Telephone Number	:	804-449-6333
Fax Number	:	804-449-6173

Authorized Official
Title or Position	:	OWNER
Name	:	HARRY BROOKS
Credential	:
Telephone Number	:	804-908-8115

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	07/19/2018

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Directions to “BEAVERDAM APOTHECARY ” Practice Location

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