Provider Demographics
NPI:1295739654
Name:JUDYS DRUG STORE INC
Entity type:Organization
Organization Name:JUDYS DRUG STORE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:JUDY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:304-257-1044
Mailing Address - Street 1:24 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847-1518
Mailing Address - Country:US
Mailing Address - Phone:304-257-1044
Mailing Address - Fax:304-257-2681
Practice Address - Street 1:24 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-1518
Practice Address - Country:US
Practice Address - Phone:304-257-1044
Practice Address - Fax:304-257-2681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X, 333600000X
WVSP05500703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0141999000Medicaid
2109313OtherPK
2109313OtherPK