Provider Demographics
NPI:1437241791
Name:MUTUAL DRUG,INC.
Entity Type:Organization
Organization Name:MUTUAL DRUG,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:CARLTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:276-523-1123
Mailing Address - Street 1:314 WOOD AVENUE E.
Mailing Address - Street 2:PO DRAWER M
Mailing Address - City:BIG STONE GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24219-0210
Mailing Address - Country:US
Mailing Address - Phone:276-523-1123
Mailing Address - Fax:276-523-4534
Practice Address - Street 1:314 WOOD AVENUE E.
Practice Address - Street 2:PO DRAWER M
Practice Address - City:BIG STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24219-0210
Practice Address - Country:US
Practice Address - Phone:276-523-1123
Practice Address - Fax:276-523-4534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010005023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4804945OtherNABP #
VA1017900001Medicare UPIN
VA4804945OtherNABP #