Provider Demographics
NPI:1023386307
Name:WILEY'S PHARMACY & COMPOUNDING SERVICES INC
Entity Type:Organization
Organization Name:WILEY'S PHARMACY & COMPOUNDING SERVICES INC
Other - Org Name:MASONS' PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:COPELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-396-1812
Mailing Address - Street 1:2403 ARKANSAS RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-8611
Mailing Address - Country:US
Mailing Address - Phone:318-396-1812
Mailing Address - Fax:318-396-5602
Practice Address - Street 1:2403 ARKANSAS RD
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-8611
Practice Address - Country:US
Practice Address - Phone:318-396-1812
Practice Address - Fax:318-396-5602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
LAPHY005903IR3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1217051Medicaid
1935963OtherNCPDP PROVIDER IDENTIFICATION NUMBER