Basic Information
| Provider Information | |||||||||
| NPI: | 1285928804 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLENDENIN HEALTH CENTER PHARMACY AT RIVERVIEW | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RIVERVIEW PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 664 | ||||||||
| Address2: | |||||||||
| City: | CLENDENIN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 250450664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045487272 | ||||||||
| FaxNumber: | 3045487149 | ||||||||
| Practice Location | |||||||||
| Address1: | 107 KOONTZ AVE | ||||||||
| Address2: | |||||||||
| City: | CLENDENIN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045487272 | ||||||||
| FaxNumber: | 3045487149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2011 | ||||||||
| LastUpdateDate: | 06/21/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3045487272 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CABIN CREEK HEALTH SYSTEMS | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | MP0552393 | 01 | WV | PHARMACY LICENSE | OTHER |