Provider Demographics
NPI:1275546426
Name:KIDWELL INC
Entity Type:Organization
Organization Name:KIDWELL INC
Other - Org Name:THE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:WISTREICH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:631-582-5959
Mailing Address - Street 1:1770 MOTOR PKWY
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5260
Mailing Address - Country:US
Mailing Address - Phone:631-582-5959
Mailing Address - Fax:631-582-6043
Practice Address - Street 1:1770 MOTOR PARKWAY
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11749
Practice Address - Country:US
Practice Address - Phone:631-582-5959
Practice Address - Fax:631-582-6043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY31103183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY021254OtherSTATE PHARMACY LICENSE