Provider Demographics
NPI:1083655765
Name:BRUNDAGES WAYMART PHARMACY
Entity Type:Organization
Organization Name:BRUNDAGES WAYMART PHARMACY
Other - Org Name:BRUNDAGES WAYMART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNDAGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:570-488-7979
Mailing Address - Street 1:PO BOX 398
Mailing Address - Street 2:
Mailing Address - City:WAYMART
Mailing Address - State:PA
Mailing Address - Zip Code:18472-0398
Mailing Address - Country:US
Mailing Address - Phone:570-488-7979
Mailing Address - Fax:570-488-7773
Practice Address - Street 1:238 BELMONT ST
Practice Address - Street 2:
Practice Address - City:WAYMART
Practice Address - State:PA
Practice Address - Zip Code:18472-9310
Practice Address - Country:US
Practice Address - Phone:570-488-7979
Practice Address - Fax:570-488-7773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
PAPP415770L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1015465050002Medicaid
3979296OtherNCPDP PROVIDER IDENTIFICATION NUMBER
PA1015465050002Medicaid