Healthcare Provider Details

I. General information

NPI: 1679110290
Provider Name (Legal Business Name): JESSICA D BOOTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2019
Last Update Date: 12/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W MAIN ST
BRIDGEPORT WV
26330-1751
US

IV. Provider business mailing address

4110 KAUSTIN DR
MORGANTOWN WV
26501-7229
US

V. Phone/Fax

Practice location:
  • Phone: 304-842-3131
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberRP0011851
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: