Provider Demographics
NPI:1245382647
Name:HAYES PROFESSIONAL SERVICE LLC
Entity Type:Organization
Organization Name:HAYES PROFESSIONAL SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-652-3711
Mailing Address - Street 1:312 DIAMOND ST
Mailing Address - Street 2:
Mailing Address - City:SISTERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26175-1354
Mailing Address - Country:US
Mailing Address - Phone:304-652-3711
Mailing Address - Fax:304-652-2371
Practice Address - Street 1:312 DIAMOND ST
Practice Address - Street 2:
Practice Address - City:SISTERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26175-1354
Practice Address - Country:US
Practice Address - Phone:304-652-3711
Practice Address - Fax:304-652-2371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV552376183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0141768000Medicaid
WV552376OtherWEST VIRGINIA STATE PHARMACY LICENSE
5011274OtherNCPDP
5011274OtherNCPDP