Provider Demographics
NPI:1326205246
Name:PETERSTOWN PHARMACY
Entity Type:Organization
Organization Name:PETERSTOWN PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:KELLEY
Authorized Official - Last Name:MASSIE
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHARMAIST
Authorized Official - Phone:304-753-5074
Mailing Address - Street 1:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:PETERSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:24963-0338
Mailing Address - Country:US
Mailing Address - Phone:304-753-5074
Mailing Address - Fax:304-753-5078
Practice Address - Street 1:105 MARKET STREET
Practice Address - Street 2:
Practice Address - City:PETERSTOWN
Practice Address - State:WV
Practice Address - Zip Code:24963
Practice Address - Country:US
Practice Address - Phone:304-753-5074
Practice Address - Fax:304-753-5078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP05522213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0141778000Medicaid
WV1239290001Medicare NSC