Provider Demographics
NPI:1427380633
Name:COMMUNITY CARE OF WEST VIRGINIA
Entity Type:Organization
Organization Name:COMMUNITY CARE OF WEST VIRGINIA
Other - Org Name:PRIMARY CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-924-6262
Mailing Address - Street 1:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:ROCK CAVE
Mailing Address - State:WV
Mailing Address - Zip Code:26234-0217
Mailing Address - Country:US
Mailing Address - Phone:304-471-2250
Mailing Address - Fax:304-924-6891
Practice Address - Street 1:122 CENTER ST
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:WV
Practice Address - Zip Code:25043-7046
Practice Address - Country:US
Practice Address - Phone:304-587-4555
Practice Address - Fax:304-587-4584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-12
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X
WVSP05523993336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2123802OtherPK