Provider Demographics
NPI:1942556527
Name:MAIN STREET PHARMACY
Entity Type:Organization
Organization Name:MAIN STREET PHARMACY
Other - Org Name:MOUNT HOPE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JAWED
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERWANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-465-7200
Mailing Address - Street 1:301 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOPE
Mailing Address - State:WV
Mailing Address - Zip Code:25880-1105
Mailing Address - Country:US
Mailing Address - Phone:304-877-7923
Mailing Address - Fax:304-877-7921
Practice Address - Street 1:301 MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT HOPE
Practice Address - State:WV
Practice Address - Zip Code:25880-1105
Practice Address - Country:US
Practice Address - Phone:304-877-7923
Practice Address - Fax:304-877-7921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-01
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP05524343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5055694OtherNCPDP PROVIDER IDENTIFICATION NUMBER