Provider Demographics
NPI:1033650098
Name:COMMUNITY CARE PHARMACY OF WEST VIRGINIA INC
Entity Type:Organization
Organization Name:COMMUNITY CARE PHARMACY OF WEST VIRGINIA INC
Other - Org Name:COMMUNITY CARE PHARMACY OF BUCKHANNON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-924-6262
Mailing Address - Street 1:37 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-2235
Mailing Address - Country:US
Mailing Address - Phone:304-472-1712
Mailing Address - Fax:304-472-1715
Practice Address - Street 1:37 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-2235
Practice Address - Country:US
Practice Address - Phone:304-472-1712
Practice Address - Fax:304-472-1715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-10
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVMP05524273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2168314OtherPK