Provider Demographics
NPI:1922196732
Name:KATHY COLLINS MCNEILL
Entity Type:Organization
Organization Name:KATHY COLLINS MCNEILL
Other - Org Name:KATHY COLLINS MCNEILL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCNEILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-864-6935
Mailing Address - Street 1:PO BOX 205
Mailing Address - Street 2:
Mailing Address - City:REEDSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26547-0205
Mailing Address - Country:US
Mailing Address - Phone:304-864-6935
Mailing Address - Fax:304-864-3910
Practice Address - Street 1:13150 VETERANS MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:REEDSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26547
Practice Address - Country:US
Practice Address - Phone:304-864-6935
Practice Address - Fax:304-864-3910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVSP05507483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0143099000Medicaid
2109796OtherPK
2109796OtherPK