MEDICARE: MAIN STREET 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	SP0552434	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5055694	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1942556527
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAIN STREET PHARMACY

Provider Business Mailing Address
First Line	:	301 MAIN ST
Second Line	:
City	:	MOUNT HOPE
State	:	WV
Zip	:	25880-1105
Country	:	US
Telephone Number	:	304-877-7923
Fax Number	:	304-877-7921

Provider Business Practice Location Address
First Line	:	301 MAIN ST
Second Line	:
City	:	MOUNT HOPE
State	:	WV
Zip	:	25880-1105
Country	:	US
Telephone Number	:	304-877-7923
Fax Number	:	304-877-7921

Authorized Official
Title or Position	:	OWNER/ PHARMACIST
Name	:	JAWED SHERWANI
Credential	:
Telephone Number	:	304-465-7200

Provider Enumeration Date	:	08/01/2012
Last Update Date	:	09/02/2014

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Directions to “MAIN STREET PHARMACY ” Practice Location

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