Provider Demographics
NPI:1538268404
Name:STONY CREEK COMMUNITY HEALTH CENTER
Entity type:Organization
Organization Name:STONY CREEK COMMUNITY HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LUCY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-246-6100
Mailing Address - Street 1:12454 HARTLEY STREET
Mailing Address - Street 2:
Mailing Address - City:STONY CREEK
Mailing Address - State:VA
Mailing Address - Zip Code:23882
Mailing Address - Country:US
Mailing Address - Phone:434-246-6100
Mailing Address - Fax:434-246-6614
Practice Address - Street 1:12451 MAIN STREET
Practice Address - Street 2:
Practice Address - City:STONY CREEK
Practice Address - State:VA
Practice Address - Zip Code:23882
Practice Address - Country:US
Practice Address - Phone:434-246-5191
Practice Address - Fax:434-246-3607
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STONY CREEK COMMUNITY HEALTH CTR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-21
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010015803336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10036267Medicaid
VA010036267Medicaid
4809820OtherNCPDP
2102912OtherPK