MEDICARE: BLACK DIAMOND PHARMACY, LLC

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	SP552244	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5011438	OTHER	WV	NABP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558444026
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK DIAMOND PHARMACY, LLC

Provider Business Mailing Address
First Line	:	PO BOX 397
Second Line	:
City	:	NORTHFORK
State	:	WV
Zip	:	24868-0397
Country	:	US
Telephone Number	:	304-862-2105
Fax Number	:	304-862-2107

Provider Business Practice Location Address
First Line	:	33800 COAL HERITAGE ROAD
Second Line	:
City	:	NORTHFORK
State	:	WV
Zip	:	24868-0397
Country	:	US
Telephone Number	:	304-862-2105
Fax Number	:	304-862-2107

Authorized Official
Title or Position	:	OWNER,MANAGER
Name	:	DAVID HENRY DUNSON
Credential	:	R.PH., CDE
Telephone Number	:	304-862-2105

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	03/07/2023

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