Provider Demographics
NPI:1154625283
Name:MAIN STREET PHARMACY INC
Entity type:Organization
Organization Name:MAIN STREET PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAWAD
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERWANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-860-1446
Mailing Address - Street 1:269 STANAFORD RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3139
Mailing Address - Country:US
Mailing Address - Phone:304-860-1446
Mailing Address - Fax:304-894-8513
Practice Address - Street 1:269 STANAFORD RD
Practice Address - Street 2:SUITE B
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3139
Practice Address - Country:US
Practice Address - Phone:304-860-1446
Practice Address - Fax:304-894-8513
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAIN STREET PHARMACY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-04
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810019416Medicaid
WV1154625283OtherBCBS
WV3810019416Medicaid