Provider Demographics
NPI:1184015802
Name:WEST VIRGINIA UNIVERSITY HOSPITALS INC
Entity Type:Organization
Organization Name:WEST VIRGINIA UNIVERSITY HOSPITALS INC
Other - Org Name:MOUNTAINEER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOEDELL
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-598-4848
Mailing Address - Street 1:PO BOX 8101
Mailing Address - Street 2:1 MEDICAL CENTER DRIVE
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26506-8101
Mailing Address - Country:US
Mailing Address - Phone:304-285-7348
Mailing Address - Fax:304-285-7349
Practice Address - Street 1:390 BIRCH STREET
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505
Practice Address - Country:US
Practice Address - Phone:304-285-7348
Practice Address - Fax:304-285-7349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-17
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
WVSP05524883336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3910006675Medicaid
2149568OtherPK