Healthcare Provider Details

I. General information

NPI: 1326205246
Provider Name (Legal Business Name): PETERSTOWN PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 06/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MARKET STREET
PETERSTOWN WV
24963
US

IV. Provider business mailing address

PO BOX 338
PETERSTOWN WV
24963-0338
US

V. Phone/Fax

Practice location:
  • Phone: 304-753-5074
  • Fax: 304-753-5078
Mailing address:
  • Phone: 304-753-5074
  • Fax: 304-753-5078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberSP0552221
License Number StateWV

VIII. Authorized Official

Name: MR. ROBERT KELLEY MASSIE JR.
Title or Position: PRESIDENT
Credential: PHARMAIST
Phone: 304-753-5074