Basic Information
| Provider Information | |||||||||
| NPI: | 1659762466 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHENANDOAH PHARMACY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1146 | ||||||||
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| City: | MARTINSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254021146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042634999 | ||||||||
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| Practice Location | |||||||||
| Address1: | 99 TAVERN RD | ||||||||
| Address2: | |||||||||
| City: | MARTINSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254012890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042634999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2015 | ||||||||
| LastUpdateDate: | 07/27/2016 | ||||||||
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| AuthorizedOfficialLastName: | FANT | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3042634999 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SHENANDOAH VALLEY MEDICAL SYSTEM, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | Y | Suppliers | Pharmacy | Clinic Pharmacy |
No ID Information.