Provider Demographics
NPI:1093881898
Name:COUNTRY ROADS PHARMACY INC
Entity Type:Organization
Organization Name:COUNTRY ROADS PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED PHARMACIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:CELENE
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-934-5327
Mailing Address - Street 1:PO BOX 460
Mailing Address - Street 2:
Mailing Address - City:GLEN DANIEL
Mailing Address - State:WV
Mailing Address - Zip Code:25844-0460
Mailing Address - Country:US
Mailing Address - Phone:304-934-5327
Mailing Address - Fax:304-934-5328
Practice Address - Street 1:109 BOLT RD
Practice Address - Street 2:
Practice Address - City:GLEN DANIEL
Practice Address - State:WV
Practice Address - Zip Code:25844-0000
Practice Address - Country:US
Practice Address - Phone:304-934-5327
Practice Address - Fax:304-934-5328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP0550106183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0139243000Medicaid
WV1140270001Medicare NSC