Provider Demographics
NPI:1558949420
Name:WELLMONT HEALTH SYSTEM
Entity Type:Organization
Organization Name:WELLMONT HEALTH SYSTEM
Other - Org Name:BH SPECIALTY PHARMACY- NOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KRUTAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-302-3423
Mailing Address - Street 1:2 PROFESSIONAL PARK DR STE 15
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6584
Mailing Address - Country:US
Mailing Address - Phone:423-434-7443
Mailing Address - Fax:423-302-3537
Practice Address - Street 1:671 HIGHWAY 58 E
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-3007
Practice Address - Country:US
Practice Address - Phone:276-439-1860
Practice Address - Fax:423-610-3365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-31
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1801826912Medicaid