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General NPI Number Information
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NPI Number | 1609154913
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Entity Type | Individual
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Provider Name | IDA MISTY NICOLE HARRIS PHARM D
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Gender | Female
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Dates
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Enumeration Date | 08/03/2011
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Last Update Date | 08/03/2011
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Provider Practice Location Address
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Address Line | 4248 COAL HERITAGE RD
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City | BLUEFIELD
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State | WV
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Zip | 24701-9190
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Country | US
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Telephone | 304-589-6868
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 29
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City | BLUEFIELD
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State | VA
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Zip | 24605-0029
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Country | US
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Telephone | 304-922-1735
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Fax |
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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 | 0007393
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License Number State | WV
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