Provider Demographics
NPI:1376158741
Name:ABBOTT, ADAM
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:ABBOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-1079
Mailing Address - Country:US
Mailing Address - Phone:304-872-4980
Mailing Address - Fax:304-872-0154
Practice Address - Street 1:700 NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-1079
Practice Address - Country:US
Practice Address - Phone:304-872-4980
Practice Address - Fax:304-872-0154
Is Sole Proprietor?:No
Enumeration Date:2020-09-12
Last Update Date:2020-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0010170183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist