Provider Demographics
NPI:1316990203
Name:OLDE TOWNE PHARMACY , INC.
Entity type:Organization
Organization Name:OLDE TOWNE PHARMACY , INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HASTY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:757-220-8764
Mailing Address - Street 1:4854 LONGHILL RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-1500
Mailing Address - Country:US
Mailing Address - Phone:757-220-8764
Mailing Address - Fax:757-229-1772
Practice Address - Street 1:4854 LONGHILL RD
Practice Address - Street 2:SUITE 5
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-1500
Practice Address - Country:US
Practice Address - Phone:757-220-8764
Practice Address - Fax:757-229-1772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201002533183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4580670001Medicare ID - Type UnspecifiedMEDICARE NUMBER
VA4822739Medicare UPIN