Provider Demographics
NPI:1689960247
Name:BUFFALO DRUG INC
Entity Type:Organization
Organization Name:BUFFALO DRUG INC
Other - Org Name:BUFFALO DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/RPH
Authorized Official - Prefix:
Authorized Official - First Name:JACKSON
Authorized Official - Middle Name:
Authorized Official - Last Name:NOEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-553-3383
Mailing Address - Street 1:PO BOX 7
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:WV
Mailing Address - Zip Code:25033-0007
Mailing Address - Country:US
Mailing Address - Phone:304-937-3000
Mailing Address - Fax:304-937-4141
Practice Address - Street 1:1905 BUFFALO ROAD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:WV
Practice Address - Zip Code:25033
Practice Address - Country:US
Practice Address - Phone:304-937-3000
Practice Address - Fax:304-937-4141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-22
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVSP05524223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2130850OtherPK
WV3810020926Medicaid