=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447864434
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALICIA AGNEW RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2020
-----------------------------------------------------
Last Update Date | 09/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 BROADWAY AVE
-----------------------------------------------------
City | PARKERSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26101-6952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-485-4533
-----------------------------------------------------
Fax | 304-485-4586
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1800 BROADWAY AVE
-----------------------------------------------------
City | PARKERSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26101-6952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-485-4533
-----------------------------------------------------
Fax | 304-485-4586
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 03227968
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RP0007061
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------