Provider Demographics
NPI:1154977023
Name:RENEGADE PHARMACY INC.
Entity type:Organization
Organization Name:RENEGADE PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-994-0635
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:OCEANA
Mailing Address - State:WV
Mailing Address - Zip Code:24870-0069
Mailing Address - Country:US
Mailing Address - Phone:304-682-0444
Mailing Address - Fax:304-682-0447
Practice Address - Street 1:RT 10 COOK PARKWAY/18 LOGAN STREET
Practice Address - Street 2:
Practice Address - City:OCEANA
Practice Address - State:WV
Practice Address - Zip Code:24870
Practice Address - Country:US
Practice Address - Phone:304-682-0444
Practice Address - Fax:304-682-0447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy