Provider Demographics
NPI:1972664043
Name:PHILLIPS DRUG LLC
Entity Type:Organization
Organization Name:PHILLIPS DRUG LLC
Other - Org Name:PHILLIPS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:RP
Authorized Official - Phone:304-652-1531
Mailing Address - Street 1:615 WELLS ST
Mailing Address - Street 2:
Mailing Address - City:SISTERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26175-1323
Mailing Address - Country:US
Mailing Address - Phone:304-652-6131
Mailing Address - Fax:304-652-1926
Practice Address - Street 1:615 WELLS ST
Practice Address - Street 2:
Practice Address - City:SISTERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26175-1323
Practice Address - Country:US
Practice Address - Phone:304-652-6131
Practice Address - Fax:304-652-1926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
WVSP05501613336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2109482OtherPK
WV00142230000Medicaid
WV00142230000Medicaid