Provider Demographics
NPI:1679073779
Name:BOONE MEMORIAL HOSPITAL, INC
Entity Type:Organization
Organization Name:BOONE MEMORIAL HOSPITAL, INC
Other - Org Name:BMH OUTPATIENT PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF DEVELOPMENT OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:GRESHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-369-2932
Mailing Address - Street 1:701 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WV
Mailing Address - Zip Code:25130-1669
Mailing Address - Country:US
Mailing Address - Phone:304-369-1230
Mailing Address - Fax:304-369-1525
Practice Address - Street 1:697 MADISON AVENUE
Practice Address - Street 2:SUITE B
Practice Address - City:MADISON
Practice Address - State:WV
Practice Address - Zip Code:25130-2513
Practice Address - Country:US
Practice Address - Phone:304-369-1230
Practice Address - Fax:304-369-1525
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOONE MEMORIAL HOSPITAL, INC.,
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3336C0002X, 3336C0003X, 3336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy