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General NPI Number Information
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NPI Number | 1164715694
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Entity Type | Individual
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Provider Name | CHARLO M JATTA PHARMACIST
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Gender | Male
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Dates
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Enumeration Date | 05/17/2011
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Last Update Date | 05/17/2011
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Provider Practice Location Address
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Address Line | 401 MORAN AVE
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City | MULLENS
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State | WV
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Zip | 25882-1430
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Country | US
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Telephone | 304-294-0343
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Fax | 304-294-7503
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Provider Business Mailing Address
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Address Line | 1191 STEWART ST 1191 STEWART STREET
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City | WELCH
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State | WV
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Zip | 24801-2133
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Country | US
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Telephone | 304-436-4938
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Fax | 304-294-7503
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | RP0004597
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License Number State | WV
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