Provider Demographics
NPI:1548861206
Name:CAMPBELL, RAYMOND GLEN
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:GLEN
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 TROY LN
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-1463
Mailing Address - Country:US
Mailing Address - Phone:304-816-2036
Mailing Address - Fax:
Practice Address - Street 1:32 TYGART MALL LOOP
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-2187
Practice Address - Country:US
Practice Address - Phone:304-366-9117
Practice Address - Fax:304-366-1583
Is Sole Proprietor?:No
Enumeration Date:2020-11-07
Last Update Date:2020-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0005216183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist