Provider Demographics
NPI:1750379632
Name:KINGWOOD PHARMACY LLC
Entity type:Organization
Organization Name:KINGWOOD PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:REESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-329-3600
Mailing Address - Street 1:220 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537-1419
Mailing Address - Country:US
Mailing Address - Phone:304-329-3600
Mailing Address - Fax:304-329-3356
Practice Address - Street 1:220 W MAIN ST
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537-1419
Practice Address - Country:US
Practice Address - Phone:304-329-3600
Practice Address - Fax:304-329-3356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVSP05508473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0143462000Medicaid
2143678OtherPK
2143678OtherPK