1710429709 NPI number — WELLNESS 1 PHARMACY- WEST

Table of content: MRS. LYDIA HALSEY MOORE MSW, LCSW (NPI 1154382349)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710429709 NPI number — WELLNESS 1 PHARMACY- WEST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLNESS 1 PHARMACY- WEST
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:
1710429709
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:
2092 S ALEX RD STE B
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
WEST CARROLLTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45449-2491
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-384-7778
Provider Business Mailing Address Fax Number:
937-384-7778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2092 S ALEX RD STE B
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
WEST CARROLLTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45449-2491
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-384-7777
Provider Business Practice Location Address Fax Number:
937-384-7778
Provider Enumeration Date:
11/08/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BOULTON
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
937-384-7777

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: PSNH.022653400- , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2166154 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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