Provider Demographics
NPI:1881692226
Name:COMMONWEALTH OF VIRGINIA SOUTHEASTERN VIRGINIA TRAINING CENTER PHARMAC
Entity type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA SOUTHEASTERN VIRGINIA TRAINING CENTER PHARMAC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:R
Authorized Official - Last Name:DAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-424-8526
Mailing Address - Street 1:4601 IRONBOUND RD
Mailing Address - Street 2:PO BOX 8791
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-2648
Mailing Address - Country:US
Mailing Address - Phone:757-253-4808
Mailing Address - Fax:757-253-4800
Practice Address - Street 1:2100 STEPPINGSTONE SQ
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-2517
Practice Address - Country:US
Practice Address - Phone:757-424-8256
Practice Address - Fax:757-424-8310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-11
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201003416183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008502137Medicaid