Provider Demographics
NPI:1538445101
Name:MOUNTAINEER MEDICAL OFFICE BUILDING PHARMACY
Entity type:Organization
Organization Name:MOUNTAINEER MEDICAL OFFICE BUILDING PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN MEMBER OF LLC
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:FRANZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-624-7200
Mailing Address - Street 1:120 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9012
Mailing Address - Country:US
Mailing Address - Phone:304-423-5200
Mailing Address - Fax:304-848-6050
Practice Address - Street 1:120 MEDICAL PARK DR STE 102
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9013
Practice Address - Country:US
Practice Address - Phone:304-423-5200
Practice Address - Fax:304-848-6050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-27
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP05524233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2132729OtherPK
WV3810022200Medicaid