Provider Demographics
NPI:1306958251
Name:WYCLIFF PHARMACY INC
Entity type:Organization
Organization Name:WYCLIFF PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:THIRD PARTY PLAN COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENA
Authorized Official - Middle Name:
Authorized Official - Last Name:FERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-993-6000
Mailing Address - Street 1:10410 MASTIN ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66212-5701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10410 MASTIN ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-5701
Practice Address - Country:US
Practice Address - Phone:913-492-4998
Practice Address - Fax:913-492-5121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS208444333600000X
3336L0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1708277OtherOTHER ID NUMBER-COMMERCIAL NUMBER
KSAW7783120OtherDEA
KS9004308Medicare PIN
KS0637250001Medicare NSC