Provider Demographics
NPI:1154845642
Name:WAYFIELD PHARMACY INC.
Entity Type:Organization
Organization Name:WAYFIELD PHARMACY INC.
Other - Org Name:WAYFIELD PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:CHINWE BIBI
Authorized Official - Middle Name:
Authorized Official - Last Name:NWABUDE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACY
Authorized Official - Phone:770-993-5520
Mailing Address - Street 1:PO BOX 767757
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-7757
Mailing Address - Country:US
Mailing Address - Phone:770-993-5520
Mailing Address - Fax:770-993-5521
Practice Address - Street 1:3050 MARTIN LUTHER KING JR DR SW
Practice Address - Street 2:UNIT H
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311-1500
Practice Address - Country:US
Practice Address - Phone:404-699-9000
Practice Address - Fax:404-699-9111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-27
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0104073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2170302OtherPK