=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063043891
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHITESVILLE FAMILY PHARMACY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2020
-----------------------------------------------------
Last Update Date | 01/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 38800 COAL RIVER RD
-----------------------------------------------------
City | WHITESVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-854-0825
-----------------------------------------------------
Fax | 304-854-0828
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 190
-----------------------------------------------------
City | SETH
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25181-0190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-837-3777
-----------------------------------------------------
Fax | 304-837-3777
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | STEPHANIE MASSEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-854-0825
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------