=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033101597
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THERA-PHARM SOLUTIONS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2005
-----------------------------------------------------
Last Update Date | 06/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 217 S GEORGIA AVE
-----------------------------------------------------
City | MARTINSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25401-1915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-263-2254
-----------------------------------------------------
Fax | 304-263-5005
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 217 S GEORGIA AVE
-----------------------------------------------------
City | MARTINSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25401-1915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-263-2254
-----------------------------------------------------
Fax | 304-263-5005
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/MANAGER
-----------------------------------------------------
Name | DR. DENVER A DEHAVEN
-----------------------------------------------------
Credential | PHARM D CGP
-----------------------------------------------------
Telephone | 304-263-2254
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 003215
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------