Provider Demographics
NPI:1861732018
Name:ALUM CREEK PHARMACY,INC
Entity type:Organization
Organization Name:ALUM CREEK PHARMACY,INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-546-7722
Mailing Address - Street 1:PO BOX 95
Mailing Address - Street 2:
Mailing Address - City:ALUM CREEK
Mailing Address - State:WV
Mailing Address - Zip Code:25003-0095
Mailing Address - Country:US
Mailing Address - Phone:304-756-2180
Mailing Address - Fax:
Practice Address - Street 1:2162 CHILDRESS RD
Practice Address - Street 2:
Practice Address - City:ALUM CREEK
Practice Address - State:WV
Practice Address - Zip Code:25003-9546
Practice Address - Country:US
Practice Address - Phone:304-756-2180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP05524443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5055795OtherNCPDP PROVIDER IDENTIFICATION NUMBER