Provider Demographics
NPI:1083719314
Name:WESTERN GREENBRIER PHARMACY INC
Entity Type:Organization
Organization Name:WESTERN GREENBRIER PHARMACY INC
Other - Org Name:WESTERN GREENBRIER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:WEED
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-392-6348
Mailing Address - Street 1:PO BOX 596
Mailing Address - Street 2:
Mailing Address - City:RUPERT
Mailing Address - State:WV
Mailing Address - Zip Code:25984-0596
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:356 NICHOLAS ST.
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:WV
Practice Address - Zip Code:25984-0596
Practice Address - Country:US
Practice Address - Phone:304-392-6348
Practice Address - Fax:304-392-6350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVSP05500803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0139165000Medicaid
2110371OtherPK
1182330001Medicare NSC