Provider Demographics
NPI:1275810616
Name:WCPS LLC
Entity Type:Organization
Organization Name:WCPS LLC
Other - Org Name:HOMETOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:HUTERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-214-3762
Mailing Address - Street 1:PO BOX 517
Mailing Address - Street 2:
Mailing Address - City:WHITLEY CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42653-0517
Mailing Address - Country:US
Mailing Address - Phone:606-376-3300
Mailing Address - Fax:606-376-3330
Practice Address - Street 1:66 CENTER AVE
Practice Address - Street 2:
Practice Address - City:WHITLEY CITY
Practice Address - State:KY
Practice Address - Zip Code:42653
Practice Address - Country:US
Practice Address - Phone:606-376-3300
Practice Address - Fax:606-376-3330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-14
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
KYP075423336C0003X
KYP078083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100231780Medicaid
2132657OtherPK
KY6841910001Medicare NSC