MEDICARE: MAIN PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	RP0002010	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053474155
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAIN PHARMACY

Provider Business Mailing Address
First Line	:	PO BOX 160
Second Line	:
City	:	MASONTOWN
State	:	WV
Zip	:	26542-0160
Country	:	US
Telephone Number	:	304-864-5711
Fax Number	:

Provider Business Practice Location Address
First Line	:	MAIN STREET
Second Line	:
City	:	MASONTOWN
State	:	WV
Zip	:	26542-0160
Country	:	US
Telephone Number	:	304-864-5711
Fax Number	:

Authorized Official
Title or Position	:	OWNER, R.PH.
Name	:	MS. LYDIA D MAIN
Credential	:
Telephone Number	:	304-864-5711

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	08/22/2020

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Directions to “MAIN PHARMACY ” Practice Location

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