Provider Demographics
NPI:1063963817
Name:MILLER, WAYNE ANDREWS (RPH)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:ANDREWS
Last Name:MILLER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 LITTLE LEAGUE RD
Mailing Address - Street 2:
Mailing Address - City:JERSEY SHORE
Mailing Address - State:PA
Mailing Address - Zip Code:17740-9009
Mailing Address - Country:US
Mailing Address - Phone:570-244-6859
Mailing Address - Fax:
Practice Address - Street 1:1129 LITTLE LEAGUE RD
Practice Address - Street 2:
Practice Address - City:JERSEY SHORE
Practice Address - State:PA
Practice Address - Zip Code:17740-9009
Practice Address - Country:US
Practice Address - Phone:570-244-6859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP032140L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP032140LOtherPHARMACY LICENSE