Provider Demographics
NPI:1366515991
Name:DANVILLE PHARMACY LLC
Entity type:Organization
Organization Name:DANVILLE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MOLES
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:304-369-3981
Mailing Address - Street 1:PO BOX 462
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25053-0462
Mailing Address - Country:US
Mailing Address - Phone:304-369-3981
Mailing Address - Fax:304-369-3983
Practice Address - Street 1:2008 SMOOT AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:WV
Practice Address - Zip Code:25053
Practice Address - Country:US
Practice Address - Phone:304-369-3981
Practice Address - Fax:304-269-3983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP0552186333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5011008OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WV0141570000Medicaid
WVBM5510436OtherDEA #
WVFD8359805OtherDEA #