Provider Demographics
NPI:1932208824
Name:WARDENSVILLE PHARMACY LLC
Entity Type:Organization
Organization Name:WARDENSVILLE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHETZEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-874-3687
Mailing Address - Street 1:PO BOX 425
Mailing Address - Street 2:
Mailing Address - City:WARDENSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26851-0425
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 EAST MAIN ST
Practice Address - Street 2:
Practice Address - City:WARDENSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26851
Practice Address - Country:US
Practice Address - Phone:304-874-3687
Practice Address - Fax:304-874-3692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP0552191333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5011060OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WV0141603000Medicaid
5011060OtherOTHER ID NUMBER-COMMERCIAL NUMBER