Provider Demographics
NPI: | 1225037260 |
---|---|
Name: | PHILLIPS PHARMACY INC. |
Entity Type: | Organization |
Organization Name: | PHILLIPS PHARMACY INC. |
Other - Org Name: | PHILLIPS PHARMACY |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | PRESIDENT/OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | TROY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | WINLAND |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 304-684-3888 |
Mailing Address - Street 1: | PO BOX 1 |
Mailing Address - Street 2: | |
Mailing Address - City: | SAINT MARYS |
Mailing Address - State: | WV |
Mailing Address - Zip Code: | 26170-0001 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 304-684-3784 |
Mailing Address - Fax: | 304-684-2358 |
Practice Address - Street 1: | 329 2ND ST |
Practice Address - Street 2: | |
Practice Address - City: | SAINT MARYS |
Practice Address - State: | WV |
Practice Address - Zip Code: | 26170-1005 |
Practice Address - Country: | US |
Practice Address - Phone: | 304-684-3784 |
Practice Address - Fax: | 304-684-2358 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2005-07-20 |
Last Update Date: | 2022-03-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 333600000X | Suppliers | Pharmacy |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WV | 0142222000 | Medicaid | |
WV | 0142222000 | Medicaid |