=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609979673
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONONGAHELA VALLEY ASSOCIATION OF HEALTH CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2006
-----------------------------------------------------
Last Update Date | 08/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1322 LOCUST AVE
-----------------------------------------------------
City | FAIRMONT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26554-1436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-366-0700
-----------------------------------------------------
Fax | 304-366-9529
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1322 LOCUST AVE PO BOX 1112
-----------------------------------------------------
City | FAIRMONT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26554-1436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-366-0700
-----------------------------------------------------
Fax | 304-366-9529
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. NANCY L VANDERGRIFT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-366-0700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0002X
-----------------------------------------------------
Taxonomy Name | Clinic Pharmacy
-----------------------------------------------------
License Number | SP0550384
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------