Basic Information
| Provider Information | |||||||||
| NPI: | 1235238122 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RAINELLE MEDICAL CENTER, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RAINELLE MEDICAL CENTER PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 176 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | RAINELLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 259621064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044386186 | ||||||||
| FaxNumber: | 3044386185 | ||||||||
| Practice Location | |||||||||
| Address1: | 176 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | RAINELLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 259621064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044386186 | ||||||||
| FaxNumber: | 3044386185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 02/20/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | YOAKUM | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PHARMACY | ||||||||
| AuthorizedOfficialTelephone: | 3044386188 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHARMD, CDE | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | SP0551235 | WV | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2111220 | 01 | PK | OTHER | 0035037003 | 05 | WV | MEDICAID |