=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326034141
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUMBERPORT PHARMACY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2005
-----------------------------------------------------
Last Update Date | 04/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 308 MAIN STREET
-----------------------------------------------------
City | LUMBERPORT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-452-7655
-----------------------------------------------------
Fax | 740-452-7655
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3506
-----------------------------------------------------
City | ZANESVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43702-3506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-452-7685
-----------------------------------------------------
Fax | 740-452-7665
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER/AO
-----------------------------------------------------
Name | JOHN COLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 740-452-7685
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | MP0552539
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------