Basic Information
| Provider Information | |||||||||
| NPI: | 1093238206 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VIRGINIA COMMONWEALTH UNIVERSITY HEALTH SYSTEM AUTHORITY | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VCU HEALTH SYSTEM - SPECIALITY PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 758997 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212750001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046286643 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1030 WILMER AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232272403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778143475 | ||||||||
| FaxNumber: | 8043646585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2017 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE AND ACCOUNTING | ||||||||
| AuthorizedOfficialTelephone: | 8046281338 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | 0202211458 | VA | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336S0011X | Y | Suppliers | Pharmacy | Specialty Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 30015174800079 | 05 | VA | MEDICAID |