Healthcare Provider Details

I. General information

NPI: 1861577090
Provider Name (Legal Business Name): TRI COUNTY HEALTH CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 04/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 QUEENS ALLY ROAD
ROCK CAVE WV
26234
US

IV. Provider business mailing address

PO BOX 217
ROCK CAVE WV
26234-0217
US

V. Phone/Fax

Practice location:
  • Phone: 304-924-6784
  • Fax: 304-924-6891
Mailing address:
  • Phone: 304-924-6784
  • Fax:

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 NumberSP0552311
License Number StateWV

VIII. Authorized Official

Name: CONNIE JOHNSTON
Title or Position: CFO
Credential:
Phone: 304-924-6262