Provider Demographics
NPI:1619050754
Name:CRAB ORCHARD PHARMACY INC
Entity Type:Organization
Organization Name:CRAB ORCHARD PHARMACY INC
Other - Org Name:CRAB ORCHARD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRES/PIC
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SALLAZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-253-7474
Mailing Address - Street 1:PO BOX 276
Mailing Address - Street 2:
Mailing Address - City:CRAB ORCHARD
Mailing Address - State:WV
Mailing Address - Zip Code:25827-0276
Mailing Address - Country:US
Mailing Address - Phone:304-253-7474
Mailing Address - Fax:304-253-7495
Practice Address - Street 1:1299 ROBERT C BYRD DRIVE
Practice Address - Street 2:
Practice Address - City:CRAB ORCHARD
Practice Address - State:WV
Practice Address - Zip Code:25827
Practice Address - Country:US
Practice Address - Phone:304-253-7474
Practice Address - Fax:304-253-7495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
WVSP05523593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV139667000Medicaid
2110661OtherPK
1032890001Medicare NSC