Basic Information
| Provider Information | |||||||||
| NPI: | 1376895995 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LINCOLN COUNTY PRIMARY CARE CENTER INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ALUM CREEK PHARMACY AT SAND PLANT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7400 LYNN AVE | ||||||||
| Address2: | |||||||||
| City: | HAMLIN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255231138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048245806 | ||||||||
| FaxNumber: | 3048246333 | ||||||||
| Practice Location | |||||||||
| Address1: | 1563 SAND PLANT RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253096120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048245806 | ||||||||
| FaxNumber: | 3047562796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2012 | ||||||||
| LastUpdateDate: | 07/19/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEACH | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3048245806 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHARM D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0002X | N | Suppliers | Pharmacy | Clinic Pharmacy | 3336C0003X | SP0552448 | WV | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 3810025585 | 05 | WV | MEDICAID | 2139374 | 01 | PK | OTHER |