Provider Demographics
NPI:1326122060
Name:JOHN MANCHIN III
Entity Type:Organization
Organization Name:JOHN MANCHIN III
Other - Org Name:THE DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANCHIN
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:304-825-6554
Mailing Address - Street 1:PO BOX 597
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26571-0597
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1021 MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:WV
Practice Address - Zip Code:26571
Practice Address - Country:US
Practice Address - Phone:304-825-1270
Practice Address - Fax:304-825-1196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVSPO5522003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0141691000Medicaid
2111318OtherPK
2111318OtherPK