Provider Demographics
NPI:1285003343
Name:FRUTH PHARAMCY INC
Entity Type:Organization
Organization Name:FRUTH PHARAMCY INC
Other - Org Name:FRUTH CENTRAL FILL # 900
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-675-1612
Mailing Address - Street 1:106 21ST ST
Mailing Address - Street 2:
Mailing Address - City:NITRO
Mailing Address - State:WV
Mailing Address - Zip Code:25143-1740
Mailing Address - Country:US
Mailing Address - Phone:304-755-9015
Mailing Address - Fax:304-755-9020
Practice Address - Street 1:106 21ST ST
Practice Address - Street 2:
Practice Address - City:NITRO
Practice Address - State:WV
Practice Address - Zip Code:25143-1740
Practice Address - Country:US
Practice Address - Phone:304-755-9015
Practice Address - Fax:304-755-9020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVMP0552419333600000X
OH0225613003336C0003X
3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2154064OtherPK