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General NPI Number Information
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NPI Number | 1497266258
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Entity Type | Organization
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Legal Business Name | MILLER BROTHERS PHARMACY LLC
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Dates
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Enumeration Date | 10/19/2017
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Last Update Date | 10/19/2017
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Provider Practice Location Address
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Address Line | 271 MAIN ST
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City | MADISON
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State | WV
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Zip | 25130-1219
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Country | US
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Telephone | 304-784-4803
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Fax |
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Provider Business Mailing Address
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Address Line | 852 OLD RIVER RD
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City | MADISON
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State | WV
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Zip | 25130-1522
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Country | US
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Telephone | 304-369-6936
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Fax |
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Authorized Official
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Title or Position | OWNER/PHARMACIST IN CHARGE
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Name | MR. SHAWN MICHAEL MILLER
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Credential | R.PH.
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Telephone | 304-784-4803
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | SP0552518
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License Number State | WV
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