Provider Demographics
NPI:1508477332
Name:WHITE HALL PHARMACY , LLC
Entity Type:Organization
Organization Name:WHITE HALL PHARMACY , LLC
Other - Org Name:WHITE HALL PHARMACY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:W
Authorized Official - Last Name:VILAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:130-429-0910
Mailing Address - Street 1:177 MIDDLETOWN RD STE 2
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-8254
Mailing Address - Country:US
Mailing Address - Phone:304-368-9355
Mailing Address - Fax:304-368-5422
Practice Address - Street 1:177 MIDDLETOWN RD STE 2
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-8254
Practice Address - Country:US
Practice Address - Phone:304-368-9355
Practice Address - Fax:304-368-5422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-14
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810013966Medicaid