Provider Demographics
NPI:1316941024
Name:WILDERNESS CENTER PHARMACY INC
Entity type:Organization
Organization Name:WILDERNESS CENTER PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:FRENCH
Authorized Official - Last Name:TRIPLETT
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:540-972-7994
Mailing Address - Street 1:5479 GERMANNA HWY
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:VA
Mailing Address - Zip Code:22508-2018
Mailing Address - Country:US
Mailing Address - Phone:540-972-7994
Mailing Address - Fax:540-972-0706
Practice Address - Street 1:5479 GERMANNA HWY
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:VA
Practice Address - Zip Code:22508-2018
Practice Address - Country:US
Practice Address - Phone:540-972-7994
Practice Address - Fax:540-972-0706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201002108183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0355600001Medicare ID - Type Unspecified