Provider Demographics
NPI:1851843965
Name:CABIN CREEK HEALTH CENTER INC
Entity Type:Organization
Organization Name:CABIN CREEK HEALTH CENTER INC
Other - Org Name:SISSONVILLE HEALTH CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCIAL ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-595-5065
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:DAWES
Mailing Address - State:WV
Mailing Address - Zip Code:25054-0070
Mailing Address - Country:US
Mailing Address - Phone:304-343-8030
Mailing Address - Fax:304-343-8031
Practice Address - Street 1:6135 SISSONVILLE DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25312-9444
Practice Address - Country:US
Practice Address - Phone:304-343-8030
Practice Address - Fax:304-343-8031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
WVMP05524283336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1851843965Medicaid
2170333OtherPK