Provider Demographics
NPI:1629099684
Name:WATERFRONT FAMILY PHARMACY LLC
Entity Type:Organization
Organization Name:WATERFRONT FAMILY PHARMACY LLC
Other - Org Name:WATERFRONT FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO OWNER AND PHARM
Authorized Official - Prefix:
Authorized Official - First Name:RACHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-225-7979
Mailing Address - Street 1:215 DON KNOTTS BLVD
Mailing Address - Street 2:STE 120
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-0113
Mailing Address - Country:US
Mailing Address - Phone:304-225-7979
Mailing Address - Fax:304-225-3784
Practice Address - Street 1:215 DON KNOTTS BLVD
Practice Address - Street 2:STE 120
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-0113
Practice Address - Country:US
Practice Address - Phone:304-225-7979
Practice Address - Fax:304-225-3784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVSP05523243336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004619Medicaid
2111571OtherPK
WV3810004619Medicaid