MEDICARE: HIGHLANDER PHARMACY INC.

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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	SP0551261	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
2	5010878	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1518955103
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIGHLANDER PHARMACY INC.

Provider Business Mailing Address
First Line	:	117 BACK FORK ST
Second Line	:
City	:	WEBSTER SPRINGS
State	:	WV
Zip	:	26288-1032
Country	:	US
Telephone Number	:	304-847-5151
Fax Number	:	304-847-2800

Provider Business Practice Location Address
First Line	:	117 BACK FORK ST
Second Line	:
City	:	WEBSTER SPRINGS
State	:	WV
Zip	:	26288-1032
Country	:	US
Telephone Number	:	304-847-5151
Fax Number	:	304-847-2800

Authorized Official
Title or Position	:	PRESIDENT AND CEO
Name	:	JEFFREY KESECKER
Credential	:
Telephone Number	:	304-847-5151

Provider Enumeration Date	:	10/09/2005
Last Update Date	:	08/31/2011

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