Provider Demographics
NPI:1033169420
Name:MAIN STREET PHARMACY, INC.
Entity Type:Organization
Organization Name:MAIN STREET PHARMACY, INC.
Other - Org Name:MAIN STREET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAWED
Authorized Official - Middle Name:ALI
Authorized Official - Last Name:SHERWANI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-465-7200
Mailing Address - Street 1:435 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OAK HILL
Mailing Address - State:WV
Mailing Address - Zip Code:25901
Mailing Address - Country:US
Mailing Address - Phone:304-465-7200
Mailing Address - Fax:304-465-0377
Practice Address - Street 1:435 W MAIN ST
Practice Address - Street 2:
Practice Address - City:OAK HILL
Practice Address - State:WV
Practice Address - Zip Code:25901
Practice Address - Country:US
Practice Address - Phone:304-465-7200
Practice Address - Fax:304-465-0377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0020031000Medicaid
WV3901170001Medicare NSC