Provider Demographics
NPI:1467546770
Name:PASTM INC
Entity Type:Organization
Organization Name:PASTM INC
Other - Org Name:MEDICAP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-523-5003
Mailing Address - Street 1:4352 5TH STREET RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-9558
Mailing Address - Country:US
Mailing Address - Phone:304-523-5003
Mailing Address - Fax:304-523-2462
Practice Address - Street 1:4352 5TH STREET RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-9558
Practice Address - Country:US
Practice Address - Phone:304-523-5003
Practice Address - Fax:304-523-2462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP0552277333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6004009000Medicaid
5011894OtherOTHER ID NUMBER-COMMERCIAL NUMBER
4405080001Medicare NSC