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NPI Code Detail

MEDICARE: COMMUNITY CARE OF WEST VIRGINIA, INC.

MEDICARE: COMMUNITY CARE OF WEST VIRGINIA, 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
13336C0003XCommunity/Retail Pharmacy

General Provider Information

NPI Number : 1639982119
Entity Type Code : Organization
Provider Name (Legal Business Name) : COMMUNITY CARE OF WEST VIRGINIA, INC.
Provider Business Mailing Address
First Line : 100 MARKET PL
Second Line :
City : BRIDGEPORT
State : WV
Zip : 26330-9168
Country : US
Telephone Number : 304-848-5774
Fax Number : 304-848-5794
Provider Business Practice Location Address
First Line : 100 MARKET PL
Second Line :
City : BRIDGEPORT
State : WV
Zip : 26330-9168
Country : US
Telephone Number : 304-848-5774
Fax Number : 304-848-5794
Authorized Official
Title or Position : CREDENTIALING COORDINATOR
Name : DORA L POTASNIK
Credential :
Telephone Number : 304-317-7275
Provider Enumeration Date : 01/29/2025
Last Update Date : 01/29/2025

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