Provider Demographics
NPI:1437252574
Name:PLEASANT VALLEY PHARMACY
Entity Type:Organization
Organization Name:PLEASANT VALLEY PHARMACY
Other - Org Name:PLEASANT VALLEY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RX MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-363-0568
Mailing Address - Street 1:49 VIP WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554
Mailing Address - Country:US
Mailing Address - Phone:304-366-3145
Mailing Address - Fax:304-363-8485
Practice Address - Street 1:49 VIP WAY
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554
Practice Address - Country:US
Practice Address - Phone:304-366-3145
Practice Address - Fax:304-363-8485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVSP05523413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006802Medicaid
2111586OtherPK