Provider Demographics
NPI:1609931732
Name:CLENDENIN PHARMACY INC
Entity Type:Organization
Organization Name:CLENDENIN PHARMACY INC
Other - Org Name:CLENDENIN PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ORE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-548-5451
Mailing Address - Street 1:PO BOX 698
Mailing Address - Street 2:
Mailing Address - City:CLENDENIN
Mailing Address - State:WV
Mailing Address - Zip Code:25045-0698
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 MAIN ST
Practice Address - Street 2:
Practice Address - City:CLENDENIN
Practice Address - State:WV
Practice Address - Zip Code:25045
Practice Address - Country:US
Practice Address - Phone:304-548-5451
Practice Address - Fax:304-548-5765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
WVSP05507593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0143182000AMedicaid
2109367OtherPK
WV0143182000AMedicaid