=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427380633
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY CARE OF WEST VIRGINIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2010
-----------------------------------------------------
Last Update Date | 07/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 122 CENTER ST
-----------------------------------------------------
City | CLAY
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25043-7046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-587-4555
-----------------------------------------------------
Fax | 304-587-4584
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 217
-----------------------------------------------------
City | ROCK CAVE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26234-0217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-471-2250
-----------------------------------------------------
Fax | 304-924-6891
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | CONNIE JOHNSTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-924-6262
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0002X
-----------------------------------------------------
Taxonomy Name | Clinic Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | SP0552399
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------