Provider Demographics
NPI:1407996382
Name:WARDENSVILLE PHARMACY LLC
Entity Type:Organization
Organization Name:WARDENSVILLE PHARMACY LLC
Other - Org Name:E A HAWSE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHETZEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-874-3687
Mailing Address - Street 1:PO BOX 31
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:WV
Mailing Address - Zip Code:26801-0031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17978 SR 55
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:WV
Practice Address - Zip Code:26801
Practice Address - Country:US
Practice Address - Phone:304-897-8220
Practice Address - Fax:304-897-8210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP0552316333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810003395Medicaid
5054072OtherOTHER ID NUMBER-COMMERCIAL NUMBER