Provider Demographics
NPI:1811090954
Name:JERRY SKEENES
Entity type:Organization
Organization Name:JERRY SKEENES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SKEENES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-756-2181
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:ALUM CREEK
Mailing Address - State:WV
Mailing Address - Zip Code:25003-0037
Mailing Address - Country:US
Mailing Address - Phone:304-756-2181
Mailing Address - Fax:304-756-2796
Practice Address - Street 1:1563 SAND PLANT RD
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-6120
Practice Address - Country:US
Practice Address - Phone:304-756-2181
Practice Address - Fax:304-756-2796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVSP05524463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5001261OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WV139035000Medicaid