Provider Demographics
NPI:1225180136
Name:BURNSVILLE DRUG STORE
Entity Type:Organization
Organization Name:BURNSVILLE DRUG STORE
Other - Org Name:BURNSVILLE DRUG STORE PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MCQUAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-853-2500
Mailing Address - Street 1:BOX 514
Mailing Address - Street 2:110 MUNICIPAL ST
Mailing Address - City:BURNSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26335
Mailing Address - Country:US
Mailing Address - Phone:304-853-2500
Mailing Address - Fax:304-853-2019
Practice Address - Street 1:110 MUNICIPAL ST
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26335
Practice Address - Country:US
Practice Address - Phone:304-853-2500
Practice Address - Fax:304-853-2019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2014-09-11
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-10-09
Provider Licenses
StateLicense IDTaxonomies
WV6062183500000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes333600000XSuppliersPharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV8500041000Medicaid