Provider Demographics
NPI:1427137199
Name:CITY CENTER PHARMACY INC
Entity type:Organization
Organization Name:CITY CENTER PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARM AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BARISCH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-344-8021
Mailing Address - Street 1:331 LAIDLEY ST
Mailing Address - Street 2:STE 101
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:331 LAIDLEY ST
Practice Address - Street 2:STE 101
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1619
Practice Address - Country:US
Practice Address - Phone:304-346-2006
Practice Address - Fax:304-344-0655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP0552269333600000X
3336C0003X, 3336C0004X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336C0004XSuppliersPharmacyCompounding Pharmacy
Not Answered3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6001226000Medicaid
5011806OtherOTHER ID NUMBER-COMMERCIAL NUMBER
5011806OtherOTHER ID NUMBER-COMMERCIAL NUMBER