Provider Demographics
NPI:1407851769
Name:JUDYS DRUG STORE INC
Entity Type:Organization
Organization Name:JUDYS DRUG STORE INC
Other - Org Name:JUDYS HEALTH EDUCATION SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:JUDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-257-1044
Mailing Address - Street 1:24 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847-1518
Mailing Address - Country:US
Mailing Address - Phone:304-257-1044
Mailing Address - Fax:304-257-2681
Practice Address - Street 1:24 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-1518
Practice Address - Country:US
Practice Address - Phone:304-257-1044
Practice Address - Fax:304-257-2681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV30133NN1002X
261Q00000X
WV51D1024349291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0141999000Medicaid
=========OtherTAX ID FOR INSURANCES
=========OtherTAX ID FOR INSURANCES
Q372210001Medicare PIN
9344971Medicare ID - Type UnspecifiedPROVIDER NUMBER
WVJU9344971Medicare PIN