Organization
LAKE CENTRE PHARMACY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ELIJAH OWEN (OWNER)
(435) 589-6622
Entity
Organization
Contact information
Practice address
4 CENTRE CT, PALMYRA, VA 22963-2329
(434) 589-6622
(434) 589-6623
Mailing address
4 CENTRE CT, PALMYRA, VA 22963-2329
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
0201003083
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4827070
OTHER ID NUMBER
—
05
—
8554471
—
VA
Enumeration date
11/03/2006
Last updated
07/03/2008
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