Provider Demographics
NPI:1053498584
Name:PATTERSON'S DRUG STORE, INC.
Entity type:Organization
Organization Name:PATTERSON'S DRUG STORE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, REG. PHARMACIST IN CHARGE
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:C
Authorized Official - Last Name:LOIZOS-HOBDAY
Authorized Official - Suffix:
Authorized Official - Credentials:BS IN PHARMACY
Authorized Official - Phone:304-267-8903
Mailing Address - Street 1:PO BOX 3060
Mailing Address - Street 2:134 S QUEEN ST
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25402
Mailing Address - Country:US
Mailing Address - Phone:304-267-8903
Mailing Address - Fax:304-267-9175
Practice Address - Street 1:134 S QUEEN ST
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401
Practice Address - Country:US
Practice Address - Phone:304-267-8903
Practice Address - Fax:304-267-9175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVMP0550777183500000X
333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0142194000Medicaid
5001235OtherNABP
5001235OtherNABP