Provider Demographics
NPI:1578033841
Name:FRUTH PHARMACY INC
Entity Type:Organization
Organization Name:FRUTH PHARMACY INC
Other - Org Name:FRUTH PHARMACY #105
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-675-1612
Mailing Address - Street 1:10 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-3745
Mailing Address - Country:US
Mailing Address - Phone:304-593-9975
Mailing Address - Fax:
Practice Address - Street 1:10 SPRING ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-3745
Practice Address - Country:US
Practice Address - Phone:304-593-9975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRUTH INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-11-29
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0552542Medicaid