Provider Demographics
NPI:1265531149
Name:DISCOUNT EMPORIUM INC
Entity type:Organization
Organization Name:DISCOUNT EMPORIUM INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:V P PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEONARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-345-4836
Mailing Address - Street 1:1601 KANAWHA BLVD W
Mailing Address - Street 2:SU 200
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25387-2539
Mailing Address - Country:US
Mailing Address - Phone:304-345-4836
Mailing Address - Fax:304-345-4972
Practice Address - Street 1:1603 KANAWHA BLVD W
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25387-2535
Practice Address - Country:US
Practice Address - Phone:304-345-3784
Practice Address - Fax:304-345-4999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
WVMP05501473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0140522000Medicaid
2110580OtherPK
0320410002Medicare NSC