Provider Demographics
NPI:1679764674
Name:CAMERON DRUG STORE, INC
Entity Type:Organization
Organization Name:CAMERON DRUG STORE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:OKEL
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:304-686-2101
Mailing Address - Street 1:1 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:WV
Mailing Address - Zip Code:26033-1130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:WV
Practice Address - Zip Code:26033-1130
Practice Address - Country:US
Practice Address - Phone:304-686-2101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP05522783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0139859000Medicaid