1194965376 NPI number — MEADOW RIVER HEALTH CARE ASSOCIATES INC

Table of content: (NPI 1194965376)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194965376 NPI number — MEADOW RIVER HEALTH CARE ASSOCIATES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEADOW RIVER HEALTH CARE ASSOCIATES 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:
CRAIGSVILLE HOMETOWN 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:
1194965376
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
512 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RAINELLE
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25962-1241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18077 WEBSTER RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRAIGSVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-742-6040
Provider Business Practice Location Address Fax Number:
304-742-6044
Provider Enumeration Date:
02/27/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BURR
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
304-742-6040

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  SP0552389 , 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: 5054995 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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