Provider Demographics
NPI:1174628408
Name:THE MEDICINE CHEST PHARMACY INC OF WV
Entity Type:Organization
Organization Name:THE MEDICINE CHEST PHARMACY INC OF WV
Other - Org Name:THE MEDICINE CHEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GILBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:FULKS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-736-8508
Mailing Address - Street 1:6245 OHIO RIVER RD
Mailing Address - Street 2:
Mailing Address - City:LESAGE
Mailing Address - State:WV
Mailing Address - Zip Code:25537-9718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6245 OHIO RIVER RD
Practice Address - Street 2:
Practice Address - City:LESAGE
Practice Address - State:WV
Practice Address - Zip Code:25537-9718
Practice Address - Country:US
Practice Address - Phone:304-736-8508
Practice Address - Fax:304-736-2806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP0550910333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5007720OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WV0143786000Medicaid
WV0143786000Medicaid