Basic Information
| Provider Information | |||||||||
| NPI: | 1881918837 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAN REXCELLENCE PROGRAM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LINCOLN COUNTY PRIMARY CARE CENTER, INC. | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7400 LYNN AVE | ||||||||
| Address2: | |||||||||
| City: | HAMLIN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255231138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048245806 | ||||||||
| FaxNumber: | 3048245804 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 E MCDONALD AVE | ||||||||
| Address2: | |||||||||
| City: | MAN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 256351023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045838585 | ||||||||
| FaxNumber: | 3045830129 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2010 | ||||||||
| LastUpdateDate: | 04/01/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARPER | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
| AuthorizedOfficialMiddleName: | ROBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 3048245806 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHARM.D, RHP | ||||||||
| NPICertificationDate: | 04/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | Y | Suppliers | Pharmacy | Clinic Pharmacy |
No ID Information.