Healthcare Provider Details

I. General information

NPI: 1003144262
Provider Name (Legal Business Name): CARNEY JERROD BROADWATER PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2009
Last Update Date: 11/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 SENECA TRL
RONCEVERTE WV
24970-1340
US

IV. Provider business mailing address

356 SENECA TRL
RONCEVERTE WV
24970-1320
US

V. Phone/Fax

Practice location:
  • Phone: 304-645-1890
  • Fax: 304-645-1891
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP0007192
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: