Basic Information
| Provider Information | |||||||||
| NPI: | 1811090954 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JERRY SKEENES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ALUM CREEK PHARMACY AT SAND PLANT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 37 | ||||||||
| Address2: | |||||||||
| City: | ALUM CREEK | ||||||||
| State: | WV | ||||||||
| PostalCode: | 250030037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047562181 | ||||||||
| FaxNumber: | 3047562796 | ||||||||
| Practice Location | |||||||||
| Address1: | 1563 SAND PLANT RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253096120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047562181 | ||||||||
| FaxNumber: | 3047562796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 03/25/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SKEENES | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3047562181 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | SP0552446 | WV | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 5001261 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER | 139035000 | 05 | WV | MEDICAID |