Basic Information
| Provider Information | |||||||||
| NPI: | 1780647461 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRI AREA COMMUNITY HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TRI-AREA COMMUNITY PHARMACY AT LAUREL FORK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9 | ||||||||
| Address2: | |||||||||
| City: | LAUREL FORK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243520009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763982292 | ||||||||
| FaxNumber: | 2763983331 | ||||||||
| Practice Location | |||||||||
| Address1: | 14558 DANVILLE PIKE | ||||||||
| Address2: | |||||||||
| City: | LAUREL FORK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243523758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763982854 | ||||||||
| FaxNumber: | 2763983331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 09/24/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WERTH | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2763982292 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | PH.D | ||||||||
| NPICertificationDate: | 09/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 008586560 | 05 | VA | MEDICAID |