Provider Demographics
NPI:1790867570
Name:PHARMACOLE INC
Entity Type:Organization
Organization Name:PHARMACOLE INC
Other - Org Name:MOUNDSVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PIC
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:TURNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:304-845-0390
Mailing Address - Street 1:118 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNDSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26041-1029
Mailing Address - Country:US
Mailing Address - Phone:304-845-0390
Mailing Address - Fax:304-845-0391
Practice Address - Street 1:118 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:MOUNDSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26041-1029
Practice Address - Country:US
Practice Address - Phone:304-845-0390
Practice Address - Fax:304-845-0391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OHNRP.022335850-033336C0003X
WVSP05507873336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0143297000Medicaid
2109812OtherPK
0372590001Medicare NSC