Provider Demographics
NPI:1922197490
Name:VILLAGE PHARMACY INC
Entity Type:Organization
Organization Name:VILLAGE PHARMACY INC
Other - Org Name:VILLAGE PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-745-3301
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:LOST CREEK
Mailing Address - State:WV
Mailing Address - Zip Code:26385-0310
Mailing Address - Country:US
Mailing Address - Phone:304-745-3301
Mailing Address - Fax:304-745-5683
Practice Address - Street 1:36 RAILROAD ST
Practice Address - Street 2:
Practice Address - City:LOST CREEK
Practice Address - State:WV
Practice Address - Zip Code:26385
Practice Address - Country:US
Practice Address - Phone:304-745-3301
Practice Address - Fax:304-745-5683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
WVSP05507913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0143308000Medicaid
2109852OtherPK
0432880001Medicare NSC