Provider Demographics
NPI:1366549297
Name:PHARMACY OF BOYKINS INC
Entity type:Organization
Organization Name:PHARMACY OF BOYKINS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-654-6271
Mailing Address - Street 1:18215 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:BOYKINS
Mailing Address - State:VA
Mailing Address - Zip Code:23827-2744
Mailing Address - Country:US
Mailing Address - Phone:757-654-6271
Mailing Address - Fax:757-654-0631
Practice Address - Street 1:18215 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:BOYKINS
Practice Address - State:VA
Practice Address - Zip Code:23827-2744
Practice Address - Country:US
Practice Address - Phone:757-654-6271
Practice Address - Fax:757-654-0631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010000593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009118551Medicaid
2102408OtherPK
VA008517789Medicaid
VA008517789Medicaid