Provider Demographics
NPI:1336118033
Name:ULTRAPHARM,INC T/A WONDER DRUG SOUTHEAST PHARMACY
Entity Type:Organization
Organization Name:ULTRAPHARM,INC T/A WONDER DRUG SOUTHEAST PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRES
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHOPSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-343-9306
Mailing Address - Street 1:1224A JAMISON AVE SE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24013-1909
Mailing Address - Country:US
Mailing Address - Phone:540-393-9306
Mailing Address - Fax:540-393-9307
Practice Address - Street 1:1224A JAMISON AVE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24013-1909
Practice Address - Country:US
Practice Address - Phone:540-393-9306
Practice Address - Fax:540-393-9307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201002967333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8545057Medicaid