Provider Demographics
NPI:1992892806
Name:MECHANICSVILLE DRUG STORE INC
Entity type:Organization
Organization Name:MECHANICSVILLE DRUG STORE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:804-746-5168
Mailing Address - Street 1:PO BOX 7
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23111-0007
Mailing Address - Country:US
Mailing Address - Phone:804-746-5168
Mailing Address - Fax:804-746-7046
Practice Address - Street 1:8077 MECHANICSVILLE TPKE
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23111-1222
Practice Address - Country:US
Practice Address - Phone:804-746-5168
Practice Address - Fax:804-746-7046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010004583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8505624Medicaid
2102079OtherPK
VA8505624Medicaid