Provider Demographics
NPI:1184022428
Name:COMMUNITY CARE OF WEST VIRGINIA, INC.
Entity Type:Organization
Organization Name:COMMUNITY CARE OF WEST VIRGINIA, INC.
Other - Org Name:COMMUNITY CARE PHARMACY OF WESTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-924-6262
Mailing Address - Street 1:107 STAUNTON DR
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WV
Mailing Address - Zip Code:26452-5604
Mailing Address - Country:US
Mailing Address - Phone:304-269-9555
Mailing Address - Fax:304-269-8409
Practice Address - Street 1:107 STAUNTON DR
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WV
Practice Address - Zip Code:26452
Practice Address - Country:US
Practice Address - Phone:304-269-9555
Practice Address - Fax:304-269-8409
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY CARE OF WEST VIRGINIA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-19
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSPO552482333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy