Provider Demographics
NPI:1962788364
Name:WILLOW DRUG INCORPORATED
Entity type:Organization
Organization Name:WILLOW DRUG INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRISON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:304-927-3784
Mailing Address - Street 1:41 WILLIAMS DR
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:WV
Mailing Address - Zip Code:25276-1825
Mailing Address - Country:US
Mailing Address - Phone:304-927-3784
Mailing Address - Fax:304-927-0333
Practice Address - Street 1:41 WILLIAMS DR
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:WV
Practice Address - Zip Code:25276-1825
Practice Address - Country:US
Practice Address - Phone:304-927-3784
Practice Address - Fax:304-927-0333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-29
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP05524283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5055606OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WV3810022178Medicaid