Provider Demographics
NPI:1003909227
Name:CHARLIES PHARMACY INC
Entity Type:Organization
Organization Name:CHARLIES PHARMACY INC
Other - Org Name:CHARLIES PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:EVA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-732-6969
Mailing Address - Street 1:PO BOX 397
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:24874-0397
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:233 MAIN ST
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:WV
Practice Address - Zip Code:24874
Practice Address - Country:US
Practice Address - Phone:304-732-6969
Practice Address - Fax:304-732-6866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP05511953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0140930000Medicaid
5010258OtherOTHER ID NUMBER-COMMERCIAL NUMBER
5010258OtherOTHER ID NUMBER
WV0140930000Medicaid