Provider Demographics
NPI:1417176041
Name:CREIGHTON CORPORATION
Entity Type:Organization
Organization Name:CREIGHTON CORPORATION
Other - Org Name:MOUNDSVILLE IGA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLLENKOPF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-612-3115
Mailing Address - Street 1:200 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNDSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26041-1001
Mailing Address - Country:US
Mailing Address - Phone:304-843-0040
Mailing Address - Fax:
Practice Address - Street 1:200 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:MOUNDSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26041-1001
Practice Address - Country:US
Practice Address - Phone:304-843-0040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVMP0552345333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVNCPDPOtherNCPDP