Provider Demographics
NPI:1598935140
Name:BAT JAC OF SOUTH CAROLINA
Entity Type:Organization
Organization Name:BAT JAC OF SOUTH CAROLINA
Other - Org Name:POCAHONTAS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBBINS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-364-5636
Mailing Address - Street 1:PO BOX 148
Mailing Address - Street 2:
Mailing Address - City:MARLINTON
Mailing Address - State:WV
Mailing Address - Zip Code:24954-0148
Mailing Address - Country:US
Mailing Address - Phone:304-799-4944
Mailing Address - Fax:304-799-4995
Practice Address - Street 1:105 DUNCAN RD
Practice Address - Street 2:STE C
Practice Address - City:MARLINTON
Practice Address - State:WV
Practice Address - Zip Code:24954
Practice Address - Country:US
Practice Address - Phone:304-799-4944
Practice Address - Fax:304-799-4995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVSP05523663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810011534Medicaid
2111733OtherPK