Provider Demographics
NPI:1457682460
Name:UBC LATE STAGE INC
Entity Type:Organization
Organization Name:UBC LATE STAGE INC
Other - Org Name:UBC LATE STAGE, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:304-291-7524
Mailing Address - Street 1:200 PINECREST PLZ
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-8065
Mailing Address - Country:US
Mailing Address - Phone:304-291-7524
Mailing Address - Fax:304-292-6391
Practice Address - Street 1:200 PINECREST PLZ
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-8065
Practice Address - Country:US
Practice Address - Phone:304-291-7524
Practice Address - Fax:304-292-6391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-15
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVMO05600833336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5055151OtherNCPDP PROVIDER IDENTIFICATION NUMBER