Provider Demographics
NPI:1073528915
Name:FRUTH PHARMACY INC
Entity Type:Organization
Organization Name:FRUTH PHARMACY INC
Other - Org Name:FRUTH PHARMACY 14
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-675-1612
Mailing Address - Street 1:FRUTH CORPORATE OFFICES
Mailing Address - Street 2:4016 OHIO RIVER RD
Mailing Address - City:WEST VIRGINIA
Mailing Address - State:WV
Mailing Address - Zip Code:25550-2127
Mailing Address - Country:US
Mailing Address - Phone:304-675-1612
Mailing Address - Fax:304-675-7905
Practice Address - Street 1:864 OAKWOOD RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-2010
Practice Address - Country:US
Practice Address - Phone:304-343-2807
Practice Address - Fax:304-720-3218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WV05501873336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0227766006Medicaid
WV1073528915Medicaid
2110644OtherPK
WV1073528915Medicaid