Provider Demographics
NPI:1629175559
Name:CLINIC PHARMACY OF PRINCETON INC
Entity Type:Organization
Organization Name:CLINIC PHARMACY OF PRINCETON INC
Other - Org Name:CLINIC PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BAY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-425-9591
Mailing Address - Street 1:508 NEW HOPE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2265
Mailing Address - Country:US
Mailing Address - Phone:304-425-9591
Mailing Address - Fax:304-425-5609
Practice Address - Street 1:508 NEW HOPE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2265
Practice Address - Country:US
Practice Address - Phone:304-425-9591
Practice Address - Fax:304-425-5609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVSP05500373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2111564OtherPK
WV3810003696Medicaid
VA008503575Medicaid
WV3810003696Medicaid