1184022428 NPI number — COMMUNITY CARE OF WEST VIRGINIA, INC.

Table of content: (NPI 1184022428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184022428 NPI number — COMMUNITY CARE OF WEST VIRGINIA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY CARE OF WEST VIRGINIA, 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:
COMMUNITY CARE PHARMACY OF WESTON
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:
1184022428
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 STAUNTON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26452-5604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-269-9555
Provider Business Mailing Address Fax Number:
304-269-8409

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 STAUNTON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-269-9555
Provider Business Practice Location Address Fax Number:
304-269-8409
Provider Enumeration Date:
12/19/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SIMON
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
304-924-6262

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  SPO552482 , 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)





Copyright © 2007-2024 www.npivalidator.com