Provider Demographics
NPI:1003936683
Name:WILEY, LARRY M (RPH)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:M
Last Name:WILEY
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 1:1210 KY HIGHWAY 36 E
Mailing Address - Street 2:SUITE G-6
Mailing Address - City:CYNTHIANA
Mailing Address - State:KY
Mailing Address - Zip Code:41031-7490
Mailing Address - Country:US
Mailing Address - Phone:859-234-2777
Mailing Address - Fax:859-234-2775
Practice Address - Street 1:1210 KY HIGHWAY 36 E
Practice Address - Street 2:SUITE G-6
Practice Address - City:CYNTHIANA
Practice Address - State:KY
Practice Address - Zip Code:41031-7490
Practice Address - Country:US
Practice Address - Phone:859-234-2777
Practice Address - Fax:859-234-2775
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007972183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist