Provider Demographics
NPI:1407889868
Name:CLARKS PHARMACY OF SALTVILLE INC
Entity Type:Organization
Organization Name:CLARKS PHARMACY OF SALTVILLE INC
Other - Org Name:CLARK'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HYLTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:276-496-7211
Mailing Address - Street 1:PO BOX S
Mailing Address - Street 2:
Mailing Address - City:SALTVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24370-1149
Mailing Address - Country:US
Mailing Address - Phone:276-496-7211
Mailing Address - Fax:276-496-5005
Practice Address - Street 1:402 PALMER AVENUE
Practice Address - Street 2:P.O. DRAWER S
Practice Address - City:SALTVILLE
Practice Address - State:VA
Practice Address - Zip Code:24370
Practice Address - Country:US
Practice Address - Phone:276-496-7211
Practice Address - Fax:276-496-5005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010001163336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2102851OtherPK
VA008501190Medicaid