Provider Demographics
NPI:1518363241
Name:COUNTRY RX LLC
Entity Type:Organization
Organization Name:COUNTRY RX LLC
Other - Org Name:COUNTRY RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:STALNAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-884-7890
Mailing Address - Street 1:134 INDUSTRIAL PARK RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JANE LEW
Mailing Address - State:WV
Mailing Address - Zip Code:26378-9785
Mailing Address - Country:US
Mailing Address - Phone:304-884-7890
Mailing Address - Fax:304-884-6807
Practice Address - Street 1:134 INDUSTRIAL PARK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:JANE LEW
Practice Address - State:WV
Practice Address - Zip Code:26378-9785
Practice Address - Country:US
Practice Address - Phone:304-884-7890
Practice Address - Fax:304-884-6807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-06
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVSP05524833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149416OtherPK