Provider Demographics
NPI:1609194505
Name:NEW RIVER HEALTH ASSOCIATION, INC.
Entity type:Organization
Organization Name:NEW RIVER HEALTH ASSOCIATION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-469-2905
Mailing Address - Street 1:497 MALL RD
Mailing Address - Street 2:
Mailing Address - City:OAK HILL
Mailing Address - State:WV
Mailing Address - Zip Code:25901-6216
Mailing Address - Country:US
Mailing Address - Phone:304-469-2905
Mailing Address - Fax:
Practice Address - Street 1:302 W. MAIN ST
Practice Address - Street 2:
Practice Address - City:SOPHIA
Practice Address - State:WV
Practice Address - Zip Code:25921
Practice Address - Country:US
Practice Address - Phone:304-683-3809
Practice Address - Fax:304-683-5761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-17
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSO05524043336C0002X
WV1036-9138261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVSP0552404OtherBOARD OF PHARMACY
WV3810020558Medicaid
WVSP0552404OtherBOARD OF PHARMACY
WV5119561Medicare PIN