Provider Demographics
NPI:1174631576
Name:PENNSBORO FAMILY PHARMACY A LIMITED LIABILITY COMPANY
Entity Type:Organization
Organization Name:PENNSBORO FAMILY PHARMACY A LIMITED LIABILITY COMPANY
Other - Org Name:FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:ECHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-659-4234
Mailing Address - Street 1:401 - A WEST MYLES AVENUE
Mailing Address - Street 2:
Mailing Address - City:PENNSBORO
Mailing Address - State:WV
Mailing Address - Zip Code:26415-1330
Mailing Address - Country:US
Mailing Address - Phone:304-659-4234
Mailing Address - Fax:304-659-4235
Practice Address - Street 1:401 - A WEST MYLES AVENUE
Practice Address - Street 2:
Practice Address - City:PENNSBORO
Practice Address - State:WV
Practice Address - Zip Code:26415-1330
Practice Address - Country:US
Practice Address - Phone:304-659-4234
Practice Address - Fax:304-659-4235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-26
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP0552234183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5011399OtherNCPDP
WV0010516000Medicaid
WV=========OtherEIN
WV=========OtherEIN