Provider Demographics
NPI:1659467637
Name:MASSIE, ROBERT KELLY JR
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:KELLY
Last Name:MASSIE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:PETERSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:24963-0338
Mailing Address - Country:US
Mailing Address - Phone:304-753-5074
Mailing Address - Fax:304-753-5078
Practice Address - Street 1:105 MARKET STREET
Practice Address - Street 2:
Practice Address - City:PETERSTOWN
Practice Address - State:WV
Practice Address - Zip Code:24963
Practice Address - Country:US
Practice Address - Phone:304-753-5074
Practice Address - Fax:304-753-5078
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0004036183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0141778000Medicaid
WV1239290001Medicare NSC