=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124656509
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DUSTIN LUCAS BAUM PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2020
-----------------------------------------------------
Last Update Date | 11/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 MEDICAL CENTER DR STE B500
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25701-3655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-691-1779
-----------------------------------------------------
Fax | 304-691-1882
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17796 HANNAN TRACE RD
-----------------------------------------------------
City | CROWN CITY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45623-9015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-447-2119
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | RP0010529
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------