Healthcare Provider Details

I. General information

NPI: 1972146314
Provider Name (Legal Business Name): FIVE STAR PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2019
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2795 RITTER DR
SHADY SPRING WV
25918-8515
US

IV. Provider business mailing address

2795 RITTER DR
SHADY SPRING WV
25918-8515
US

V. Phone/Fax

Practice location:
  • Phone: 304-573-1114
  • Fax:
Mailing address:
  • Phone: 304-573-1114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LESLIE DIANE SISSON
Title or Position: CO-OWNER
Credential: RPH
Phone: 304-573-1114