Provider Demographics
NPI:1194355172
Name:WYOMING PHARMACY LLC
Entity type:Organization
Organization Name:WYOMING PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:SAIFUL
Authorized Official - Middle Name:
Authorized Official - Last Name:ISLAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:407-967-6840
Mailing Address - Street 1:333 E WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-4434
Mailing Address - Country:US
Mailing Address - Phone:215-333-1555
Mailing Address - Fax:
Practice Address - Street 1:333 E WYOMING AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-4434
Practice Address - Country:US
Practice Address - Phone:215-333-1555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-18
Last Update Date:2020-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPP482943OtherSTATE BOARD