Provider Demographics
NPI:1336339704
Name:TUG VALLEY PHARMACY LLC
Entity Type:Organization
Organization Name:TUG VALLEY PHARMACY LLC
Other - Org Name:TUG VALLEY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:BALLENGEE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:304-235-8080
Mailing Address - Street 1:PO BOX 538
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-0538
Mailing Address - Country:US
Mailing Address - Phone:304-235-0080
Mailing Address - Fax:304-235-1699
Practice Address - Street 1:54 W 2ND AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3506
Practice Address - Country:US
Practice Address - Phone:304-235-8080
Practice Address - Fax:304-235-1699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV5970210001Medicare NSC