Basic Information
| Provider Information | |||||||||
| NPI: | 1619333515 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WIRT COUNTY HEALTH SERVICES ASSOCIATION, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PARKERSBURG FAMILY CARE PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2610 CAMDEN AVE | ||||||||
| Address2: | |||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261015652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049173739 | ||||||||
| FaxNumber: | 3049173751 | ||||||||
| Practice Location | |||||||||
| Address1: | 2610 CAMDEN AVE | ||||||||
| Address2: | |||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261015652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049173739 | ||||||||
| FaxNumber: | 3049173751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2016 | ||||||||
| LastUpdateDate: | 01/17/2017 | ||||||||
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| AuthorizedOfficialLastName: | SNYDER | ||||||||
| AuthorizedOfficialFirstName: | DEREK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3042758780 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0002X | N | Suppliers | Pharmacy | Clinic Pharmacy | 3336C0003X | MP0552422 | WV | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2157359 | 01 | PK | OTHER |