Provider Demographics
NPI:1417054255
Name:GOODYKOONTZ DRUG STORES INC
Entity Type:Organization
Organization Name:GOODYKOONTZ DRUG STORES INC
Other - Org Name:GOODYKOONTZ DRUG STORE INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOVENIZER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-324-7601
Mailing Address - Street 1:2924 EAST CUMBERLAND ROAD
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701
Mailing Address - Country:US
Mailing Address - Phone:304-325-7121
Mailing Address - Fax:304-327-9701
Practice Address - Street 1:2924 EAST CUMBERLAND ROAD
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701
Practice Address - Country:US
Practice Address - Phone:304-325-7121
Practice Address - Fax:304-327-9701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
WVSP05500983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0085046995Medicaid
WV0141899000Medicaid
2109351OtherPK
WV0141899000Medicaid