Basic Information
Provider Information | |||||||||
NPI: | 1336661834 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RAINELLE MEDICAL CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MAXWELTON HEALTH CENTER PHARMACY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 176 MEDICAL CENTER DR | ||||||||
Address2: |   | ||||||||
City: | RAINELLE | ||||||||
State: | WV | ||||||||
PostalCode: | 259621064 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3044386188 | ||||||||
FaxNumber: | 3044386185 | ||||||||
Practice Location | |||||||||
Address1: | 390 INDUSTRIAL PARK RD | ||||||||
Address2: |   | ||||||||
City: | MAXWELTON | ||||||||
State: | WV | ||||||||
PostalCode: | 249578073 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6813183610 | ||||||||
FaxNumber: | 6813183613 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2017 | ||||||||
LastUpdateDate: | 07/17/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YOAKUM | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF PHARMACY | ||||||||
AuthorizedOfficialTelephone: | 3044386188 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | RAINELLE MEDICAL CENTER, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHARMD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | SP0552512 | WV | Y |   | Suppliers | Pharmacy |   |
No ID Information.