Provider Demographics
NPI:1073695854
Name:PRUNTYS PHARMACY INC
Entity Type:Organization
Organization Name:PRUNTYS PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUNTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-758-4300
Mailing Address - Street 1:717 WELLS ST
Mailing Address - Street 2:
Mailing Address - City:SISTERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26175-1325
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:717 WELLS ST
Practice Address - Street 2:
Practice Address - City:SISTERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26175-1325
Practice Address - Country:US
Practice Address - Phone:304-652-3711
Practice Address - Fax:304-652-2371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP0552272333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1073695854OtherMEDICARE NPI
WV2119415Medicaid
WV0139623001Medicaid
5003532OtherOTHER ID NUMBER-COMMERCIAL NUMBER