Provider Demographics
NPI:1033575592
Name:MTWELCOME PHARMACY PRINCESSE
Entity Type:Organization
Organization Name:MTWELCOME PHARMACY PRINCESSE
Other - Org Name:MT WELCOME PHARMACY PRINCESSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-890-3409
Mailing Address - Street 1:4040 ESTATE LA GRANDE PRINCESS
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSTED
Mailing Address - State:VI
Mailing Address - Zip Code:00820-5165
Mailing Address - Country:US
Mailing Address - Phone:340-719-7979
Mailing Address - Fax:340-713-3118
Practice Address - Street 1:4040 LA GRANDE PRINCESS
Practice Address - Street 2:
Practice Address - City:CHRISTIANSTED
Practice Address - State:VI
Practice Address - Zip Code:00820
Practice Address - Country:US
Practice Address - Phone:340-719-7979
Practice Address - Fax:340-713-3118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
VI2-13924-3L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2157468OtherPK
VI1262Medicaid