Provider Demographics
NPI:1073737003
Name:PROCARE PHARMACY INC.
Entity Type:Organization
Organization Name:PROCARE PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MRS
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-592-2680
Mailing Address - Street 1:720 PIKE ST
Mailing Address - Street 2:
Mailing Address - City:SHINNSTON
Mailing Address - State:WV
Mailing Address - Zip Code:26431-1435
Mailing Address - Country:US
Mailing Address - Phone:304-592-2680
Mailing Address - Fax:304-592-2684
Practice Address - Street 1:720 PIKE ST
Practice Address - Street 2:
Practice Address - City:SHINNSTON
Practice Address - State:WV
Practice Address - Zip Code:26431-1435
Practice Address - Country:US
Practice Address - Phone:304-592-2680
Practice Address - Fax:304-592-2684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP05523013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6003088000Medicaid
WV4978810001Medicare NSC
WV6003088000Medicaid