Provider Demographics
NPI:1366500431
Name:STROUD COMPOUNDING AND WELLNESS DRUGSTORE CORP
Entity Type:Organization
Organization Name:STROUD COMPOUNDING AND WELLNESS DRUGSTORE CORP
Other - Org Name:STROUD COMPOUNDING AND WELLNESS DRUGSTORE, CORP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CHIKWANHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-476-6936
Mailing Address - Street 1:1619 N 9TH ST
Mailing Address - Street 2:STE 3
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-6501
Mailing Address - Country:US
Mailing Address - Phone:570-476-6936
Mailing Address - Fax:570-476-6938
Practice Address - Street 1:1619 N 9TH ST
Practice Address - Street 2:STE 3
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-6501
Practice Address - Country:US
Practice Address - Phone:570-476-6936
Practice Address - Fax:570-476-6938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
PAPP4816513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2136912OtherPK
PA1027704260001Medicaid