Provider Demographics
NPI:1881753218
Name:ROBERT E DUTTON
Entity type:Organization
Organization Name:ROBERT E DUTTON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER RPH
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:DUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-295-9594
Mailing Address - Street 1:3201 GRAND CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-1539
Mailing Address - Country:US
Mailing Address - Phone:304-295-9594
Mailing Address - Fax:304-295-0422
Practice Address - Street 1:3201 GRAND CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-1539
Practice Address - Country:US
Practice Address - Phone:304-295-9594
Practice Address - Fax:304-295-0422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP0550050333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0139009000Medicaid
WV0139009000Medicaid
5008354Medicare UPIN