MEDICARE: BLANDS DRUG STORE

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
2	333600000X	Pharmacy
3	332B00000X	Durable Medical Equipment & Medical Supplies
4	3336C0004X	Compounding Pharmacy	SP0550017	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	5000980	OTHER	OTHER ID NUMBER

General Provider Information

NPI Number	:	1790780377
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLANDS DRUG STORE

Provider Business Mailing Address
First Line	:	217 W PIKE ST
Second Line	:
City	:	CLARKSBURG
State	:	WV
Zip	:	26301-2750
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	217 W PIKE ST
Second Line	:
City	:	CLARKSBURG
State	:	WV
Zip	:	26301-2750
Country	:	US
Telephone Number	:	304-624-5491
Fax Number	:	304-623-0830

Authorized Official
Title or Position	:	PIC
Name	:	BRENDA FOX
Credential	:
Telephone Number	:	304-624-5491

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	09/13/2007

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Directions to “BLANDS DRUG STORE ” Practice Location

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