Basic Information
| Provider Information | |||||||||
| NPI: | 1144536137 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VIRGINIA COMMONWEALTH UNIVERSITY HEALTH SYSTEM AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VCUHS-EMPLOYEE PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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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: | 1250 E MARSHALL ST | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232985051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046282426 | ||||||||
| FaxNumber: | 8046280545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2010 | ||||||||
| LastUpdateDate: | 08/31/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE AND ACCOUNTING | ||||||||
| AuthorizedOfficialTelephone: | 8046281338 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 0201001878 | VA | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 4842589 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER | 8506744 | 05 | VA | MEDICAID |