Healthcare Provider Details

I. General information

NPI: 1962647719
Provider Name (Legal Business Name): WHITEHALL PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2008
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 MIDDLETOWN RD SUITE 2
FAIRMONT WV
26554-8254
US

IV. Provider business mailing address

177 MIDDLETOWN RD SUITE 2
FAIRMONT WV
26554-8254
US

V. Phone/Fax

Practice location:
  • Phone: 304-368-9355
  • Fax: 304-368-5422
Mailing address:
  • Phone: 304-368-9355
  • Fax: 304-368-5422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberMP0552374
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TERRI VILAIN
Title or Position: RPH/OWNER
Credential:
Phone: 304-368-9355