Provider Demographics
NPI:1730242298
Name:CLINCH VALLEY PHARMACY
Entity type:Organization
Organization Name:CLINCH VALLEY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:STANSBURY
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:276-988-4871
Mailing Address - Street 1:PO BOX 548
Mailing Address - Street 2:
Mailing Address - City:TAZEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:24651-0548
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:160 MARTINGALE DR
Practice Address - Street 2:
Practice Address - City:TAZEWELL
Practice Address - State:VA
Practice Address - Zip Code:24651-7000
Practice Address - Country:US
Practice Address - Phone:276-988-4871
Practice Address - Fax:276-988-6966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201002840333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4809983OtherOTHER ID NUMBER-COMMERCIAL NUMBER
VA8502374Medicaid
WV0141752000Medicaid
VA8502374Medicaid