1104233329 NPI number — PHARMACOLE INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104233329 NPI number — PHARMACOLE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHARMACOLE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SISTERSVILLE PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104233329
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
118 LAFAYETTE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNDSVILLE
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26041-1029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-845-0390
Provider Business Mailing Address Fax Number:
304-845-0391

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
312 DIAMOND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SISTERSVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26175-1354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-652-3711
Provider Business Practice Location Address Fax Number:
304-652-2371
Provider Enumeration Date:
07/21/2014

Additional Information

Authorized Official

Authorized Official Last Name:
TURNER
Authorized Official First Name:
JASON
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST
Authorized Official Telephone Number:
304-845-0390

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  SP0552376 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2146947 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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