Healthcare Provider Details

I. General information

NPI: 1083719314
Provider Name (Legal Business Name): WESTERN GREENBRIER PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

356 NICHOLAS ST.
RUPERT WV
25984-0596
US

IV. Provider business mailing address

PO BOX 596
RUPERT WV
25984-0596
US

V. Phone/Fax

Practice location:
  • Phone: 304-392-6348
  • Fax: 304-392-6350
Mailing address:
  • Phone:
  • 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 NumberSP0550080
License Number StateWV

VIII. Authorized Official

Name: ROBERT WEED
Title or Position: OWNER
Credential: R.PH.
Phone: 304-392-6348