Provider Demographics
NPI:1871731448
Name:JEFFERSON PHARMACY
Entity type:Organization
Organization Name:JEFFERSON PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-589-7902
Mailing Address - Street 1:194 TURKEYSAG TRL STE B
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:VA
Mailing Address - Zip Code:22963-2661
Mailing Address - Country:US
Mailing Address - Phone:434-589-7902
Mailing Address - Fax:434-589-7912
Practice Address - Street 1:194 TURKEYSAG TRL STE B
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:VA
Practice Address - Zip Code:22963-2661
Practice Address - Country:US
Practice Address - Phone:434-589-7902
Practice Address - Fax:434-589-7912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-04
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
VA02010042683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2118991OtherPK
VA1871731448Medicaid
6918750001Medicare NSC