Provider Demographics
NPI:1326034141
Name:LUMBERPORT PHARMACY, INC
Entity type:Organization
Organization Name:LUMBERPORT PHARMACY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER/AO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-452-7685
Mailing Address - Street 1:PO BOX 3506
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43702-3506
Mailing Address - Country:US
Mailing Address - Phone:740-452-7685
Mailing Address - Fax:740-452-7665
Practice Address - Street 1:308 MAIN STREET
Practice Address - Street 2:
Practice Address - City:LUMBERPORT
Practice Address - State:WV
Practice Address - Zip Code:26386
Practice Address - Country:US
Practice Address - Phone:740-452-7655
Practice Address - Fax:740-452-7655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WVMP05525393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1326034141Medicaid
Q620870001OtherMEDICARE