Provider Demographics
NPI:1487726014
Name:MIDDLESEX PHARMACY INC
Entity type:Organization
Organization Name:MIDDLESEX PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAROLL
Authorized Official - Middle Name:
Authorized Official - Last Name:THROCKMORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-436-3615
Mailing Address - Street 1:9893 GENERAL PULLER HWY
Mailing Address - Street 2:
Mailing Address - City:HARTFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23071-3122
Mailing Address - Country:US
Mailing Address - Phone:804-776-9990
Mailing Address - Fax:804-776-9991
Practice Address - Street 1:9893 GENERAL PULLER HWY
Practice Address - Street 2:
Practice Address - City:HARTFIELD
Practice Address - State:VA
Practice Address - Zip Code:23071-3122
Practice Address - Country:US
Practice Address - Phone:804-776-9990
Practice Address - Fax:804-776-9991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
VA02010021023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008514402Medicaid
2139221OtherPK