Provider Demographics
NPI:1326147216
Name:PRUNTYS PHARMACY INC
Entity Type:Organization
Organization Name:PRUNTYS PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:PUNTY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-758-4300
Mailing Address - Street 1:PO BOX 28
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBOURNE
Mailing Address - State:WV
Mailing Address - Zip Code:26149-0028
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBOURNE
Practice Address - State:WV
Practice Address - Zip Code:26149
Practice Address - Country:US
Practice Address - Phone:304-758-4300
Practice Address - Fax:304-758-4365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP0550195333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5009116OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WV0139623000Medicaid
WV0204780001Medicare NSC