Provider Demographics
NPI:1306505763
Name:MAIN STREET PHARMACY INC
Entity type:Organization
Organization Name:MAIN STREET PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:A
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-465-7200
Mailing Address - Street 1:4501 MACCORKLE AVE SW STE 101
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1444
Mailing Address - Country:US
Mailing Address - Phone:304-766-8484
Mailing Address - Fax:304-766-8344
Practice Address - Street 1:4501 MACCORKLE AVE SW STE 101
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1444
Practice Address - Country:US
Practice Address - Phone:304-766-8484
Practice Address - Fax:304-766-8344
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAIN STREET PHARMACY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy