Provider Demographics
NPI:1336208727
Name:PLAZA LTC PHARMACY
Entity type:Organization
Organization Name:PLAZA LTC PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHIBLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH, MBA
Authorized Official - Phone:804-864-0276
Mailing Address - Street 1:1717 BELLEVUE AVE APT A605
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-3936
Mailing Address - Country:US
Mailing Address - Phone:804-864-0276
Mailing Address - Fax:804-864-0275
Practice Address - Street 1:1717 BELLEVUE AVE APT A605
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227-3936
Practice Address - Country:US
Practice Address - Phone:804-864-0276
Practice Address - Fax:804-864-0275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010039583336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0155060001Medicare NSC
VAP00186803Medicare PIN