Provider Demographics
NPI:1235718214
Name:SPATAFORE, LORI (RPH)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:SPATAFORE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1847
Mailing Address - Country:US
Mailing Address - Phone:304-848-9500
Mailing Address - Fax:304-848-9503
Practice Address - Street 1:460 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1847
Practice Address - Country:US
Practice Address - Phone:304-848-9500
Practice Address - Fax:304-848-9503
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00006236183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist