Provider Demographics
NPI:1871080853
Name:CENTRA CANCER CENTER PHARMACY, LLC
Entity type:Organization
Organization Name:CENTRA CANCER CENTER PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HOSPITAL PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:CULBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-200-3014
Mailing Address - Street 1:1701 THOMSON DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1118
Mailing Address - Country:US
Mailing Address - Phone:434-200-1435
Mailing Address - Fax:434-200-7508
Practice Address - Street 1:1701 THOMSON DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501
Practice Address - Country:US
Practice Address - Phone:434-200-1435
Practice Address - Fax:434-200-7508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-16
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010048283336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1871080853Medicaid
2176972OtherPK