Provider Demographics
NPI:1285928804
Name:CLENDENIN HEALTH CENTER PHARMACY AT RIVERVIEW
Entity type:Organization
Organization Name:CLENDENIN HEALTH CENTER PHARMACY AT RIVERVIEW
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-548-7272
Mailing Address - Street 1:PO BOX 664
Mailing Address - Street 2:
Mailing Address - City:CLENDENIN
Mailing Address - State:WV
Mailing Address - Zip Code:25045-0664
Mailing Address - Country:US
Mailing Address - Phone:304-548-7272
Mailing Address - Fax:304-548-7149
Practice Address - Street 1:107 KOONTZ AVE
Practice Address - Street 2:
Practice Address - City:CLENDENIN
Practice Address - State:WV
Practice Address - Zip Code:25045
Practice Address - Country:US
Practice Address - Phone:304-548-7272
Practice Address - Fax:304-548-7149
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CABIN CREEK HEALTH SYSTEMS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-31
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVMP0552393OtherPHARMACY LICENSE