Healthcare Provider Details

I. General information

NPI: 1942556527
Provider Name (Legal Business Name): MAIN STREET PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2012
Last Update Date: 09/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MAIN ST
MOUNT HOPE WV
25880-1105
US

IV. Provider business mailing address

301 MAIN ST
MOUNT HOPE WV
25880-1105
US

V. Phone/Fax

Practice location:
  • Phone: 304-877-7923
  • Fax: 304-877-7921
Mailing address:
  • Phone: 304-877-7923
  • Fax: 304-877-7921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberSP0552434
License Number StateWV

VIII. Authorized Official

Name: JAWED SHERWANI
Title or Position: OWNER/ PHARMACIST
Credential:
Phone: 304-465-7200