Provider Demographics
NPI:1992802821
Name:FORT CHISWELL PHARMACY INC
Entity type:Organization
Organization Name:FORT CHISWELL PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRUNYAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-637-3178
Mailing Address - Street 1:791 FORT CHISWELL RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MAX MEADOWS
Mailing Address - State:VA
Mailing Address - Zip Code:24360-4139
Mailing Address - Country:US
Mailing Address - Phone:276-637-3178
Mailing Address - Fax:276-637-4158
Practice Address - Street 1:791 FORT CHISWELL RD
Practice Address - Street 2:SUITE B
Practice Address - City:MAX MEADOWS
Practice Address - State:VA
Practice Address - Zip Code:24360-4139
Practice Address - Country:US
Practice Address - Phone:276-637-3178
Practice Address - Fax:276-637-4158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010025903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8504156Medicaid
2104830OtherPK