Basic Information
| Provider Information | |||||||||
| NPI: | 1225191224 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRITZ S PHARMACY AND WELLNESS CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MEDWORKS PHARMACY AND WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 370 SENECA TRL | ||||||||
| Address2: | |||||||||
| City: | RONCEVERTE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249701340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046451890 | ||||||||
| FaxNumber: | 3046456246 | ||||||||
| Practice Location | |||||||||
| Address1: | 370 SENECA TRL | ||||||||
| Address2: | |||||||||
| City: | RONCEVERTE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249701340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046451890 | ||||||||
| FaxNumber: | 3046456246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 10/08/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CUNNINGHAM | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 3046456245 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | ACCOUNTANT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | SP0552293 | WV | Y | 193400000X SINGLE SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 6003057000 | 05 | WV | MEDICAID |