Provider Demographics
NPI:1760493258
Name:WELLMONT HEALTH SYSTEM
Entity Type:Organization
Organization Name:WELLMONT HEALTH SYSTEM
Other - Org Name:THE BIG STONE GAP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRMCT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KAY
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:276-523-8702
Mailing Address - Street 1:1980 HOLTON AVE E # 1
Mailing Address - Street 2:
Mailing Address - City:BIG STONE GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24219-3366
Mailing Address - Country:US
Mailing Address - Phone:276-523-8702
Mailing Address - Fax:276-523-8750
Practice Address - Street 1:1980 HOLTON AVE E # 1
Practice Address - Street 2:
Practice Address - City:BIG STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24219-3366
Practice Address - Country:US
Practice Address - Phone:276-523-8702
Practice Address - Fax:276-523-8750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010029983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4826547OtherNCPDP PROVIDER IDENTIFICATION NUMBER
VA8543909Medicaid
KY54032909Medicaid