Provider Demographics
NPI:1306945266
Name:LIVELY DRUG COMPANY INC
Entity type:Organization
Organization Name:LIVELY DRUG COMPANY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:THOAMS
Authorized Official - Middle Name:
Authorized Official - Last Name:BEANE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:804-462-5644
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:LIVELY
Mailing Address - State:VA
Mailing Address - Zip Code:22507-0399
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36 LIVELY OAKS RD
Practice Address - Street 2:STATE RT 3
Practice Address - City:LIVELY
Practice Address - State:VA
Practice Address - Zip Code:22507
Practice Address - Country:US
Practice Address - Phone:804-462-5644
Practice Address - Fax:804-462-5667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010004273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8503516Medicaid
4806824OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0249500001Medicare NSC