Healthcare Provider Details

I. General information

NPI: 1144459520
Provider Name (Legal Business Name): LARRY H PRUNTY RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2009
Last Update Date: 07/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 UNDERWOOD ST
MIDDLEBOURNE WV
26149-9657
US

IV. Provider business mailing address

300 UNDERWOOD ST
MIDDLEBOURNE WV
26149-9657
US

V. Phone/Fax

Practice location:
  • Phone: 304-758-2816
  • Fax: 304-758-4365
Mailing address:
  • Phone: 304-758-2816
  • Fax: 304-758-4365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number3852
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: