Healthcare Provider Details

I. General information

NPI: 1710084645
Provider Name (Legal Business Name): CROSS LANES FAMILY PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 GOFF MOUNTAIN RD
CROSS LANES WV
25313-1430
US

IV. Provider business mailing address

107 GOFF MOUNTAIN RD
CROSS LANES WV
25313-1430
US

V. Phone/Fax

Practice location:
  • Phone: 304-204-2588
  • Fax: 304-204-2591
Mailing address:
  • Phone: 304-204-2588
  • Fax: 304-204-2591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberSP0552317
License Number StateWV

VIII. Authorized Official

Name: BRAC BROWN
Title or Position: PHARMACIST SOLE OWNER
Credential: RPH
Phone: 304-204-2588