Provider Demographics
NPI:1700253861
Name:BP4 LLC
Entity Type:Organization
Organization Name:BP4 LLC
Other - Org Name:BYPASS PHARMACY # 4
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SIDDARTHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ILANGOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-222-3064
Mailing Address - Street 1:104 S EISENHOWER DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-4930
Mailing Address - Country:US
Mailing Address - Phone:304-222-3064
Mailing Address - Fax:304-253-3982
Practice Address - Street 1:5151 MACCORKLE AVE SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1109
Practice Address - Country:US
Practice Address - Phone:304-766-0900
Practice Address - Fax:304-766-0901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-25
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVMP05524183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2153688OtherPK