Provider Demographics
NPI:1225191224
Name:FRITZ S PHARMACY AND WELLNESS CENTER
Entity Type:Organization
Organization Name:FRITZ S PHARMACY AND WELLNESS CENTER
Other - Org Name:MEDWORKS PHARMACY AND WELLNESS CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:ACCOUNTANT
Authorized Official - Phone:304-645-6245
Mailing Address - Street 1:370 SENECA TRL
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-1340
Mailing Address - Country:US
Mailing Address - Phone:304-645-1890
Mailing Address - Fax:304-645-6246
Practice Address - Street 1:370 SENECA TRL
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-1340
Practice Address - Country:US
Practice Address - Phone:304-645-1890
Practice Address - Fax:304-645-6246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP0552293183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6003057000Medicaid
WV4590450002Medicare ID - Type UnspecifiedMEDICARE PROVIDER #