Provider Demographics
NPI:1851460703
Name:PAUL G. STAKIAS
Entity Type:Organization
Organization Name:PAUL G. STAKIAS
Other - Org Name:PENN WAY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:G
Authorized Official - Last Name:STAKIAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-748-0505
Mailing Address - Street 1:3159 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-4711
Mailing Address - Country:US
Mailing Address - Phone:304-748-0505
Mailing Address - Fax:304-748-4436
Practice Address - Street 1:3159 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-4711
Practice Address - Country:US
Practice Address - Phone:304-748-0505
Practice Address - Fax:304-748-4436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
WVSP05502093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0142197000Medicaid
2109491OtherPK
2109491OtherPK