Healthcare Provider Details

I. General information

NPI: 1568807394
Provider Name (Legal Business Name): CHARLES EDWARD BISH RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2013
Last Update Date: 05/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 GOFF MOUNTAIN RD SUITE #5
CROSS LANES WV
25313-6602
US

IV. Provider business mailing address

314 GOFF MOUNTAIN RD SUITE #5
CROSS LANES WV
25313-6602
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-7050
  • Fax: 304-388-7055
Mailing address:
  • Phone: 304-388-7050
  • Fax: 304-388-7055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberWV 4932
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: