Provider Demographics
NPI:1265449235
Name:WESLEY HEALTH CARE CENTER INC
Entity Type:Organization
Organization Name:WESLEY HEALTH CARE CENTER INC
Other - Org Name:WESLEY HEALTH CARE CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:L CLIFFORD
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-691-1461
Mailing Address - Street 1:131 LAWRENCE ST
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-1346
Mailing Address - Country:US
Mailing Address - Phone:518-587-3600
Mailing Address - Fax:518-691-1640
Practice Address - Street 1:131 LAWRENCE ST
Practice Address - Street 2:
Practice Address - City:SARATOGA SPGS
Practice Address - State:NY
Practice Address - Zip Code:12866-1346
Practice Address - Country:US
Practice Address - Phone:518-587-3600
Practice Address - Fax:518-691-1640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336I0012X
NY0182663336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02181666Medicaid
2062270OtherPK