Provider Demographics
NPI:1154491967
Name:CLAY SUPERMARKET INC
Entity Type:Organization
Organization Name:CLAY SUPERMARKET INC
Other - Org Name:CLAY FOODLAND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DREAMA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLIFTON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-587-2777
Mailing Address - Street 1:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:WV
Mailing Address - Zip Code:25043-0609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 MAIN ST
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:WV
Practice Address - Zip Code:25043-0609
Practice Address - Country:US
Practice Address - Phone:304-587-7327
Practice Address - Fax:304-587-4888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVSP05509423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5008013OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WV0144001000Medicaid
5008013OtherNCPDP PROVIDER IDENTIFICATION NUMBER