1700036258 NPI number — WAYNE LTC PHARMACY INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700036258 NPI number — WAYNE LTC PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAYNE LTC PHARMACY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700036258
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 89
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14513-0089
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-594-2222
Provider Business Mailing Address Fax Number:
315-594-2227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12018 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOLCOTT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14590-1022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-594-2222
Provider Business Practice Location Address Fax Number:
315-594-2227
Provider Enumeration Date:
09/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PYNN
Authorized Official First Name:
DARREN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
315-594-2222

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 029086 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2117616 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 03074884 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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