Provider Demographics
NPI:1376846576
Name:BOOTH, JUSTIN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:BOOTH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1264
Mailing Address - Street 2:
Mailing Address - City:MOUNT GAY
Mailing Address - State:WV
Mailing Address - Zip Code:25637-1264
Mailing Address - Country:US
Mailing Address - Phone:304-239-2380
Mailing Address - Fax:304-239-2384
Practice Address - Street 1:US ROUTE 119 HOLDEN ROAD
Practice Address - Street 2:
Practice Address - City:MOUNT GAY
Practice Address - State:WV
Practice Address - Zip Code:25637-1264
Practice Address - Country:US
Practice Address - Phone:304-239-2380
Practice Address - Fax:304-239-2384
Is Sole Proprietor?:No
Enumeration Date:2010-12-09
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV7030183500000X
TN034037183500000X
FL46090183500000X
KY014618183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist