Provider Demographics
NPI:1508985599
Name:BALLENGEE, SAMUEL RANDOLPH (PHARMD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:RANDOLPH
Last Name:BALLENGEE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 538
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-0538
Mailing Address - Country:US
Mailing Address - Phone:304-475-0080
Mailing Address - Fax:304-475-0080
Practice Address - Street 1:54 W 2ND AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3506
Practice Address - Country:US
Practice Address - Phone:304-475-0080
Practice Address - Fax:304-475-0080
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0006318183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist