Provider Demographics
NPI:1235238122
Name:RAINELLE MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:RAINELLE MEDICAL CENTER, INC.
Other - Org Name:RAINELLE MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:YOAKUM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, CDE
Authorized Official - Phone:304-438-6188
Mailing Address - Street 1:176 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:RAINELLE
Mailing Address - State:WV
Mailing Address - Zip Code:25962-1064
Mailing Address - Country:US
Mailing Address - Phone:304-438-6186
Mailing Address - Fax:304-438-6185
Practice Address - Street 1:176 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:RAINELLE
Practice Address - State:WV
Practice Address - Zip Code:25962-1064
Practice Address - Country:US
Practice Address - Phone:304-438-6186
Practice Address - Fax:304-438-6185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVSP05512353336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2111220OtherPK
WV0035037003Medicaid
2111220OtherPK