Provider Demographics
NPI:1962647719
Name:WHITEHALL PHARMACY LLC
Entity Type:Organization
Organization Name:WHITEHALL PHARMACY LLC
Other - Org Name:WHITE HALL PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:VILAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-368-9355
Mailing Address - Street 1:177 MIDDLETOWN RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-8254
Mailing Address - Country:US
Mailing Address - Phone:304-368-9355
Mailing Address - Fax:304-368-5422
Practice Address - Street 1:177 MIDDLETOWN RD
Practice Address - Street 2:SUITE 2
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-8254
Practice Address - Country:US
Practice Address - Phone:304-368-9355
Practice Address - Fax:304-368-5422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-09
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
WVMP05523743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810013966Medicaid
2118003OtherPK