Provider Demographics
NPI:1053474155
Name:MAIN PHARMACY
Entity Type:Organization
Organization Name:MAIN PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, R.PH.
Authorized Official - Prefix:MS
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-864-5711
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:MASONTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26542-0160
Mailing Address - Country:US
Mailing Address - Phone:304-864-5711
Mailing Address - Fax:
Practice Address - Street 1:MAIN STREET
Practice Address - Street 2:
Practice Address - City:MASONTOWN
Practice Address - State:WV
Practice Address - Zip Code:26542-0160
Practice Address - Country:US
Practice Address - Phone:304-864-5711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP00020103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0142032000Medicaid
WV0142032000Medicaid