Provider Demographics
NPI:1699781492
Name:WISHBONE ENTERPRISES LLC
Entity type:Organization
Organization Name:WISHBONE ENTERPRISES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:X
Authorized Official - Last Name:KONICKI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:570-378-2885
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:LAKE WINOLA
Mailing Address - State:PA
Mailing Address - Zip Code:18625-0279
Mailing Address - Country:US
Mailing Address - Phone:570-378-2885
Mailing Address - Fax:570-378-2962
Practice Address - Street 1:ROUTE 307 WINOLA PLAZA
Practice Address - Street 2:
Practice Address - City:LAKE WINOLA
Practice Address - State:PA
Practice Address - Zip Code:18625-2962
Practice Address - Country:US
Practice Address - Phone:570-378-2885
Practice Address - Fax:570-378-2962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP414435L183500000X, 3336C0003X
PARP032206L332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3962330OtherNABP
PA1007440510001Medicaid
PA1007440510001Medicaid