Provider Demographics
NPI:1558444026
Name:BLACK DIAMOND PHARMACY, LLC
Entity Type:Organization
Organization Name:BLACK DIAMOND PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER,MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:DUNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, CDE
Authorized Official - Phone:304-862-2105
Mailing Address - Street 1:PO BOX 397
Mailing Address - Street 2:
Mailing Address - City:NORTHFORK
Mailing Address - State:WV
Mailing Address - Zip Code:24868-0397
Mailing Address - Country:US
Mailing Address - Phone:304-862-2105
Mailing Address - Fax:304-862-2107
Practice Address - Street 1:33800 COAL HERITAGE ROAD
Practice Address - Street 2:
Practice Address - City:NORTHFORK
Practice Address - State:WV
Practice Address - Zip Code:24868-0397
Practice Address - Country:US
Practice Address - Phone:304-862-2105
Practice Address - Fax:304-862-2107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP5522443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV5011438OtherNABP
WV0008503000Medicaid
WV0008503000Medicaid
WVBB6283321OtherDEA