Healthcare Provider Details

I. General information

NPI: 1215988670
Provider Name (Legal Business Name): WESTSIDE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RT 10 COOK PKWY AND LOGAN ST
OCEANA WV
24870
US

IV. Provider business mailing address

PO BOX 69
OCEANA WV
24870-0069
US

V. Phone/Fax

Practice location:
  • Phone: 304-682-0444
  • Fax: 304-682-0447
Mailing address:
  • Phone: 304-682-0444
  • Fax: 304-682-0447

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 NumberSP0552334
License Number StateWV

VIII. Authorized Official

Name: DEVONNA MILLER WEST
Title or Position: PRESIDENT
Credential: DRPH
Phone: 304-682-0444