Provider Demographics
NPI:1891970414
Name:COAL RIVER PHARMACY LLC
Entity type:Organization
Organization Name:COAL RIVER PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-837-3777
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:SETH
Mailing Address - State:WV
Mailing Address - Zip Code:25181-0190
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21189 COAL RIVER RD
Practice Address - Street 2:
Practice Address - City:COMFORT
Practice Address - State:WV
Practice Address - Zip Code:25049
Practice Address - Country:US
Practice Address - Phone:304-837-3777
Practice Address - Fax:304-837-3776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
WVSP05523653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810011065Medicaid
2111653OtherPK
2111653OtherPK