Provider Demographics
NPI:1366179616
Name:COMMUNITY CARE OF WEST VIRGINIA, INC.
Entity type:Organization
Organization Name:COMMUNITY CARE OF WEST VIRGINIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DORA
Authorized Official - Middle Name:L
Authorized Official - Last Name:POTASNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-317-7275
Mailing Address - Street 1:4498 POTOMAC HIGHLANDS TRIAL
Mailing Address - Street 2:
Mailing Address - City:GREEN BANK
Mailing Address - State:WV
Mailing Address - Zip Code:24944
Mailing Address - Country:US
Mailing Address - Phone:304-456-3333
Mailing Address - Fax:304-456-3070
Practice Address - Street 1:4498 POTOMAC HIGHLANDS TRIAL
Practice Address - Street 2:
Practice Address - City:GREEN BANK
Practice Address - State:WV
Practice Address - Zip Code:24944
Practice Address - Country:US
Practice Address - Phone:304-456-3333
Practice Address - Fax:304-456-3070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVMP0552572OtherPHARMACY LICENSE