Provider Demographics
NPI:1952849093
Name:MADISON FAMILY PHARMACY, LLC
Entity Type:Organization
Organization Name:MADISON FAMILY PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BURDETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-369-0209
Mailing Address - Street 1:313 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WV
Mailing Address - Zip Code:25130-1510
Mailing Address - Country:US
Mailing Address - Phone:304-369-0209
Mailing Address - Fax:304-369-1994
Practice Address - Street 1:313 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WV
Practice Address - Zip Code:25130-1510
Practice Address - Country:US
Practice Address - Phone:304-369-0209
Practice Address - Fax:304-369-1994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP05525093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy