Basic Information
| Provider Information | |||||||||
| NPI: | 1508824301 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HUNTINGTON VAMC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | HUNTINGTON VAMC PHARMACY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 94496 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441014496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282572333 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1540 SPRING VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257049300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044296755 | ||||||||
| FaxNumber: | 3044297564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 04/12/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POTTER | ||||||||
| AuthorizedOfficialFirstName: | ERIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | NPI TEAM MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2023822579 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332100000X | Y | Suppliers | Department of Veterans Affairs (VA) Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 5004673 | 01 | WV | NCPDP# | OTHER |