Provider Demographics
NPI:1477646693
Name:PENDLETON COMMUNITY CARE, INC.
Entity Type:Organization
Organization Name:PENDLETON COMMUNITY CARE, INC.
Other - Org Name:PILL BOX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-358-2355
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WV
Mailing Address - Zip Code:26807-0189
Mailing Address - Country:US
Mailing Address - Phone:304-358-2887
Mailing Address - Fax:304-358-3149
Practice Address - Street 1:203 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WV
Practice Address - Zip Code:26807
Practice Address - Country:US
Practice Address - Phone:304-358-2887
Practice Address - Fax:304-358-3149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVSP05523833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2119084OtherPK
WV3810014185Medicaid
WV3810014185Medicaid
WV6372520001Medicare NSC