Basic Information
| Provider Information | |||||||||
| NPI: | 1265623094 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRANT MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GRANT MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 117 HOSPITAL DR | ||||||||
| Address2: | PO BOX 1019 | ||||||||
| City: | PETERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 268479566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042571026 | ||||||||
| FaxNumber: | 3042579622 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 268479566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042571026 | ||||||||
| FaxNumber: | 3042579622 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2007 | ||||||||
| LastUpdateDate: | 02/16/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARMAN | ||||||||
| AuthorizedOfficialFirstName: | BRENTON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PIC | ||||||||
| AuthorizedOfficialTelephone: | 3042571026 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0004X | N | Suppliers | Pharmacy | Compounding Pharmacy | 332BP3500X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 3336I0012X | IP0550877 | WV | Y | Suppliers | Pharmacy | Institutional Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2109651 | 01 | PK | OTHER |