MEDICARE: GOODYKOONTZ DRUG STORES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336L0003X	Long Term Care Pharmacy
3	3336C0003X	Community/Retail Pharmacy	SP0550098	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	2109351	OTHER	PK

General Provider Information

NPI Number	:	1417054255
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOODYKOONTZ DRUG STORES INC

Provider Business Mailing Address
First Line	:	2924 EAST CUMBERLAND ROAD
Second Line	:
City	:	BLUEFIELD
State	:	WV
Zip	:	24701
Country	:	US
Telephone Number	:	304-325-7121
Fax Number	:	304-327-9701

Provider Business Practice Location Address
First Line	:	2924 EAST CUMBERLAND ROAD
Second Line	:
City	:	BLUEFIELD
State	:	WV
Zip	:	24701
Country	:	US
Telephone Number	:	304-325-7121
Fax Number	:	304-327-9701

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JERRY BOVENIZER
Credential	:	RPH
Telephone Number	:	304-324-7601

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	09/19/2016

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Directions to “GOODYKOONTZ DRUG STORES INC ” Practice Location

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